CASE REPORT
Scalp Trauma: A Risk Factor for Lichen Planopilaris? Renee-Anne Montpellier and Jeff C. Donovan Background: Lichen planopilaris is a type of primary scarring alopecia that is characterized by perifollicular lymphocytic inflammation and fibrosis. The cause remains poorly understood, although recent research has begun to unravel some of the molecular mechanisms implicated in the pathogenesis. Objective: To present a case of biopsy-proven lichen planopilaris in a patient who had previously suffered serious head injury. Lichen planopilaris developed only in the areas of trauma. Conclusion: Our findings highlight the possible association between scalp trauma and the development of lichen planopilaris. Further research is needed to understand the role of scalp trauma in the pathogenesis of scarring alopecia. Contexte: Le lichen plano-pilaire est un type d’alope´cie de cicatrisation primaire, qui se caracte´rise par une inflammation lymphocytaire pe´rifolliculaire et par de la fibrose. La cause est obscure, mais des travaux re´cents de recherche ont commence´ a` mettre en e´vidence certains me´canismes mole´culaires, incrimine´s dans la pathogene`se. Objectif: L’e´tude visait a` exposer un cas de lichen plano-pilaire, ave´re´ a` la biopsie, chez un patient qui avait e´te´ victime, dans le passe´, d’un trauma craˆnien grave. Le lichen plano-pilaire ne se de´veloppe que dans les re´gions ayant subi des le´sions traumatiques. Conclusions: Les re´sultats de l’e´tude font ressortir l’association possible entre les traumas du cuir chevelu et l’apparition de lichen plano-pilaire; toutefois, d’autres recherches s’imposent afin de faire la lumie`re sur le roˆle du trauma du cuir chevelu dans la pathogene`se de l’alope´cie cicatricielle.
ICHEN PLANOPILARIS (LPP) is a type of primary lymphocytic cicatricial alopecia.1 The disease typically occurs between the fourth and sixth decades of life and often presents with symptoms such as hair loss, scalp pruritus, tenderness, or pain.1,2 Histologically, LPP is characterized by a perifollicular predominantly lymphocytic infiltrate that eventually leads to perifollicular fibrosis en route to complete destruction of the hair follicle. The underlying cause is not fully understood, but a leading theory implicates an autoimmune process. Recent research has highlighted the importance of the cellular peroxisome proliferator–activated receptor gamma (PPARgamma) signaling pathway. Mice with a targeted deletion of PPAR-gamma developed a skin pathology closely resembling LPP.3
L
From the Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON. Address reprint requests to: Jeff C. Donovan, MD, PhD, FRCPC, Hair Loss Clinic, RKS Dermatology Centre, Women’s College Hospital, 76 Grenville Street, 5th Floor, Toronto, ON M5S 1B2; e-mail: jeffrey. [email protected].
DOI 10.2310/7750.2013.13020 # 2014 Canadian Dermatology Association
214
An association between traumatic injury in the development of LPP was recently described.4 Herein we describe a case of LPP following serious head trauma.
Case Report A 70-year-old male presented with a 30-year history of hair loss in the crown accompanied by mild scalp pruritus, burning, and tenderness in the affected areas. He sought medical attention because his hair loss was now more difficult to conceal. On further questioning, the patient revealed that he had been involved in a motor vehicle collision as a teenager and had suffered a serious head injury. During examination, it was noted that he had some areas of atrophic scarring that were devoid of hair. In the periphery, some follicles showed perifollicular erythema and scale (Figure 1). A 4 mm punch biopsy was obtained from the affected area (Figure 2). Histologically, there was a decrease in the number of hair follicles with loss of sebaceous glands. One hair follicle showed perifollicular fibrosis and a mild inflammatory infiltrate of a few lymphocytes and plasma cells. Most striking, however, were the changes in the papillary and reticular dermis with collagen bundles and fibroblasts running parallel to the epidermis.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 214–216
Scalp Trauma as Risk Factor for Lichen Planopilaris
Discussion
Figure 1. Scarring alopecia (lichen planopilaris) developing at the site of previous scalp trauma.
Taken together, these histologic findings are consistent with a scarring alopecia developing within a scar. The clinical and histologic features of the scarring alopecia fit best with a diagnosis of LPP.
LPP is viewed as an autoimmune lymphocytic cicatricial alopecia for which the cause remains unknown.1 Central to the pathogenesis is an autoimmune-based T-lymphocyte attack against the follicular antigens.5 A number of triggers of lichen planus have been reported, including viruses and medications. Our patient developed LPP at the site of previous head trauma, raising the question as to whether traumatic injury may also be added to the list of triggers. The Koebner phenomenon (isomorphic response) was first described in 1876 and refers to the development of cutaneous lesions at the site of tissue insult.6 The Koebner phenomenon has been documented in a number of cases of lichen planus of the skin as well as lichen planus of the mouth.7 Most recently, Monselise and colleagues reported a patient who developed scalp LPP following many years of repeated scalp trauma secondary to break dancing.4 In addition, Donovan as well as Chiang and colleagues reported the development of LPP following hair transplant surgery,8,9 raising the possibility that surgical trauma may be also be relevant to some cases of LPP. The considerable time delay between the individual’s injury and his development of LPP raises the question as to how direct the link, if any, might be. However, the fact that his LPP developed at the exact site of his injury is intriquing and warrants further investigation. There are a number of changes in scar tissue, such as the presence of chronic mast cells and changes at the level of the vascularity, that make it an ideal area for koebnerization to occur.4 Recent research has also shown an interesting connection between traumatic skin injury and downregulation of PPAR gamma.10 Given the known role for PPAR-gamma downregulation in stimulating LPP-like changes in hair follicles, further research may uncover whether scalp trauma is a bona fide trigger for some cases of LPP.
Acknowledgment Financial disclosure of authors and reviewers: None reported. Figure 2. A 4 mm punch biopsy of the scalp showed loss of sebaceous glands with collagen bundles and fibroblasts oriented parallel to the epidermis (true scar). The hair follicle showed perifollicular fibrosis and a mild inflammatory infiltrate of a few lymphocytes and plasma cells (hematoxylin-eosin stain; 340 original magnification).
References 1. Ross EK, Tan E, Shapiro J. Update on primary cicatricial alopecias. J Am Acad Dermatol 2005;53:1–37, doi:10.1016/j.jaad.2004.06.015.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 214–216
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2. Kang H, Alzolibani AA, Otberg N, Shapiro J. Lichen planopilaris. Dermatol Ther 2008;21:249–56, doi:10.1111/j.1529-8019.2008. 00206.x. 3. Karnik P, Tekeste Z, McCormick TS, et al. Hair follicle stem cellspecific deletion causes scarring alopecia. J Invest Dermatol 2009; 129:1243–57, doi:10.1038/jid.2008.369. 4. Monselise A, Chan L, Shapiro J. Break dancing: a new risk factor for scarring hair loss. J Cutan Med Surg 2011;15:177–9. 5. Sharma A, Bialynicki-Birula R, Schwartz RA, et al. Lichen planus: an update and review. Cutis 2012;90:17–23. 6. Sagi L, Trau H. The Koebner phenomenon. Clin Dermatol 2011; 29:231–6, doi:10.1016/j.clindermatol.2010.09.014.
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7. Farhi D, Dupin N. Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies. Clin Dermatol 2010;28:100–8, doi:10.1016/j.clindermatol.2009.03.004. 8. Donovan J. Lichen planopilaris after hair transplantation: report of 17 cases. Dermatol Surg 2012;38:1998–2004, doi:10.1111/dsu.12014. 9. Chiang YZ, Tosti A, Chaudry IH, et al. Lichen planopilaris following hair transplantation and facelift surgery. Br J Dermatol 2012;166:666–370, doi:10.1111/j.1365-2133.2011.10692.x. 10. Neher MD, Weckbach S, Huber-Lang MS, et al. New insights into the role of peroxisome proliferator-activated receptors in regulating the inflammatory response after tissue injury. PPAR Res 2012; 2012:728461, doi:10.1155/2012/728461.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 214–216
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Scalp Trauma: A Risk Factor for Lichen Planopilaris? Renee-Anne Montpellier and Jeff C. Donovan Background: Lichen planopilaris is a type of primary scarring alopecia that is characterized by perifollicular lymphocytic inflammation and fibrosis. The cause remains poorly understood, although recent research has begun to unravel some of the molecular mechanisms implicated in the pathogenesis. Objective: To present a case of biopsy-proven lichen planopilaris in a patient who had previously suffered serious head injury. Lichen planopilaris developed only in the areas of trauma. Conclusion: Our findings highlight the possible association between scalp trauma and the development of lichen planopilaris. Further research is needed to understand the role of scalp trauma in the pathogenesis of scarring alopecia. Contexte: Le lichen plano-pilaire est un type d’alope´cie de cicatrisation primaire, qui se caracte´rise par une inflammation lymphocytaire pe´rifolliculaire et par de la fibrose. La cause est obscure, mais des travaux re´cents de recherche ont commence´ a` mettre en e´vidence certains me´canismes mole´culaires, incrimine´s dans la pathogene`se. Objectif: L’e´tude visait a` exposer un cas de lichen plano-pilaire, ave´re´ a` la biopsie, chez un patient qui avait e´te´ victime, dans le passe´, d’un trauma craˆnien grave. Le lichen plano-pilaire ne se de´veloppe que dans les re´gions ayant subi des le´sions traumatiques. Conclusions: Les re´sultats de l’e´tude font ressortir l’association possible entre les traumas du cuir chevelu et l’apparition de lichen plano-pilaire; toutefois, d’autres recherches s’imposent afin de faire la lumie`re sur le roˆle du trauma du cuir chevelu dans la pathogene`se de l’alope´cie cicatricielle.
ICHEN PLANOPILARIS (LPP) is a type of primary lymphocytic cicatricial alopecia.1 The disease typically occurs between the fourth and sixth decades of life and often presents with symptoms such as hair loss, scalp pruritus, tenderness, or pain.1,2 Histologically, LPP is characterized by a perifollicular predominantly lymphocytic infiltrate that eventually leads to perifollicular fibrosis en route to complete destruction of the hair follicle. The underlying cause is not fully understood, but a leading theory implicates an autoimmune process. Recent research has highlighted the importance of the cellular peroxisome proliferator–activated receptor gamma (PPARgamma) signaling pathway. Mice with a targeted deletion of PPAR-gamma developed a skin pathology closely resembling LPP.3
L
From the Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON. Address reprint requests to: Jeff C. Donovan, MD, PhD, FRCPC, Hair Loss Clinic, RKS Dermatology Centre, Women’s College Hospital, 76 Grenville Street, 5th Floor, Toronto, ON M5S 1B2; e-mail: jeffrey. [email protected].
DOI 10.2310/7750.2013.13020 # 2014 Canadian Dermatology Association
214
An association between traumatic injury in the development of LPP was recently described.4 Herein we describe a case of LPP following serious head trauma.
Case Report A 70-year-old male presented with a 30-year history of hair loss in the crown accompanied by mild scalp pruritus, burning, and tenderness in the affected areas. He sought medical attention because his hair loss was now more difficult to conceal. On further questioning, the patient revealed that he had been involved in a motor vehicle collision as a teenager and had suffered a serious head injury. During examination, it was noted that he had some areas of atrophic scarring that were devoid of hair. In the periphery, some follicles showed perifollicular erythema and scale (Figure 1). A 4 mm punch biopsy was obtained from the affected area (Figure 2). Histologically, there was a decrease in the number of hair follicles with loss of sebaceous glands. One hair follicle showed perifollicular fibrosis and a mild inflammatory infiltrate of a few lymphocytes and plasma cells. Most striking, however, were the changes in the papillary and reticular dermis with collagen bundles and fibroblasts running parallel to the epidermis.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 214–216
Scalp Trauma as Risk Factor for Lichen Planopilaris
Discussion
Figure 1. Scarring alopecia (lichen planopilaris) developing at the site of previous scalp trauma.
Taken together, these histologic findings are consistent with a scarring alopecia developing within a scar. The clinical and histologic features of the scarring alopecia fit best with a diagnosis of LPP.
LPP is viewed as an autoimmune lymphocytic cicatricial alopecia for which the cause remains unknown.1 Central to the pathogenesis is an autoimmune-based T-lymphocyte attack against the follicular antigens.5 A number of triggers of lichen planus have been reported, including viruses and medications. Our patient developed LPP at the site of previous head trauma, raising the question as to whether traumatic injury may also be added to the list of triggers. The Koebner phenomenon (isomorphic response) was first described in 1876 and refers to the development of cutaneous lesions at the site of tissue insult.6 The Koebner phenomenon has been documented in a number of cases of lichen planus of the skin as well as lichen planus of the mouth.7 Most recently, Monselise and colleagues reported a patient who developed scalp LPP following many years of repeated scalp trauma secondary to break dancing.4 In addition, Donovan as well as Chiang and colleagues reported the development of LPP following hair transplant surgery,8,9 raising the possibility that surgical trauma may be also be relevant to some cases of LPP. The considerable time delay between the individual’s injury and his development of LPP raises the question as to how direct the link, if any, might be. However, the fact that his LPP developed at the exact site of his injury is intriquing and warrants further investigation. There are a number of changes in scar tissue, such as the presence of chronic mast cells and changes at the level of the vascularity, that make it an ideal area for koebnerization to occur.4 Recent research has also shown an interesting connection between traumatic skin injury and downregulation of PPAR gamma.10 Given the known role for PPAR-gamma downregulation in stimulating LPP-like changes in hair follicles, further research may uncover whether scalp trauma is a bona fide trigger for some cases of LPP.
Acknowledgment Financial disclosure of authors and reviewers: None reported. Figure 2. A 4 mm punch biopsy of the scalp showed loss of sebaceous glands with collagen bundles and fibroblasts oriented parallel to the epidermis (true scar). The hair follicle showed perifollicular fibrosis and a mild inflammatory infiltrate of a few lymphocytes and plasma cells (hematoxylin-eosin stain; 340 original magnification).
References 1. Ross EK, Tan E, Shapiro J. Update on primary cicatricial alopecias. J Am Acad Dermatol 2005;53:1–37, doi:10.1016/j.jaad.2004.06.015.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 214–216
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Montpellier and Donovan
2. Kang H, Alzolibani AA, Otberg N, Shapiro J. Lichen planopilaris. Dermatol Ther 2008;21:249–56, doi:10.1111/j.1529-8019.2008. 00206.x. 3. Karnik P, Tekeste Z, McCormick TS, et al. Hair follicle stem cellspecific deletion causes scarring alopecia. J Invest Dermatol 2009; 129:1243–57, doi:10.1038/jid.2008.369. 4. Monselise A, Chan L, Shapiro J. Break dancing: a new risk factor for scarring hair loss. J Cutan Med Surg 2011;15:177–9. 5. Sharma A, Bialynicki-Birula R, Schwartz RA, et al. Lichen planus: an update and review. Cutis 2012;90:17–23. 6. Sagi L, Trau H. The Koebner phenomenon. Clin Dermatol 2011; 29:231–6, doi:10.1016/j.clindermatol.2010.09.014.
216
7. Farhi D, Dupin N. Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies. Clin Dermatol 2010;28:100–8, doi:10.1016/j.clindermatol.2009.03.004. 8. Donovan J. Lichen planopilaris after hair transplantation: report of 17 cases. Dermatol Surg 2012;38:1998–2004, doi:10.1111/dsu.12014. 9. Chiang YZ, Tosti A, Chaudry IH, et al. Lichen planopilaris following hair transplantation and facelift surgery. Br J Dermatol 2012;166:666–370, doi:10.1111/j.1365-2133.2011.10692.x. 10. Neher MD, Weckbach S, Huber-Lang MS, et al. New insights into the role of peroxisome proliferator-activated receptors in regulating the inflammatory response after tissue injury. PPAR Res 2012; 2012:728461, doi:10.1155/2012/728461.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 214–216
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
