Case 112

Two different dermatologists have diagnosed me with LPP of facial hairs. I am 23 years old and was diagnosed with LPP at 18. My LPP is localized to the side of my face. I have normal facial hairs on the front of my face and on the neck but on the both sides of my face I have red bumps and hairs are scarce compared to the moustache, chin and neck. The skin is red and inflamed on the side too but I have not experienced any hair loss to the hairs that already came out on my face. However, as mentioned before the hairs on the side of my face have these red flat bumps and the hair is also scarce and thinner on the side of my face. Let me also say these red flat bumps are not itchy or irritating.

I have photos below so you can review my case. I would really appreciate your reply because although two dermatologists have diagnosed me with LPP, I haven’t experienced hair loss for 5 years of battling this condition with no treatment either.

My condition has not progressed and every now and then I see individual hair follicle sprouting out on the side of my face. I have tried tacrolimus ointment to control the inflammation on the doctors recommendation but I feel that makes it worse so I stopped using.

Is this really LPP and what treatment is best given the steroids can make my skin thinner and tacrolimus makes it worse. At this young age the inflamed red bumps really affect my normal life and mental health and I hope you can understand that.

As far as further information is concerned I do have a history of battling skin conditions related to hair. I have keratosis pilaris (chicken legs and bumps on arms) since I was a child. Three years ago I also developed a small bump on my scalp. A dermatologist said it too is a scarring alopecia. I have taken topical medication and oral tetracycline on the doctors advice and it has improved significantly. It is only a small localized spot on the top of my head. Otherwise my hairs are all healthy.

At my young age, the inflamed red bumps really affect my normal life and mental health. I hope you can understand that.

QUESTION

a) Is this really LPP and if so - what treatment is best given the steroids can make my skin thinner and tacrolimus makes it worse.

b) What is keratosis pilaris spinulosa decalvans? Do I have this? Why or why not?

c) What is atrophoderma vermiculatum? Do I have this? Why or why not?

d) What is Keratosis pilaris atrophicans faciei? Do I have this? Why or why not?

Case 113

I am feeling very confused and was hoping to get your opinion on my hair loss.

For background, I’m a 29 year old male. I started noticing crown hair loss in December 2023, although from pictures it likely started in late 2022. After seeing a dermatologist, I started topical minoxidil 5% in December 2023 and saw no results. I also had bumps, which I was told were folliculitis. My dermatologist thought I had AGA (there is a history of this in my family), mostly with crown loss but also some minor temple recession. At follow up in July 2024, the derm thought he saw scarring and ordered a biopsy which showed “perrifollicular lymphocytic inflammation and perifollicular fibrosis at the infundibulum, and fibrotic tracts, some of which contain adjacent arrector pili muscles”.

After the biopsy, I was started on clobetasol propionate.

I switched derms for a second opinion—this derm added doxycycline 200mg/day and switched me to 2.5 mg of oral minoxidil for 2 months. He didn’t think I had LPP or CCCA, as I had only minimal redness (and not really centered around the follicle), no real scale, and no burning (I do have mild “tingling” that occurs in the area of hair loss on the crown, but also in the back and front of my scalp). My only strange symptom besides hair loss are these bumps/pimples/pustules.

At 2 month follow up after starting doxycycline and oral minoxidil in October 2024, the second dermatologist had me half the doxycycline to 100mg/day and stop clobetasol so I could get rebiopsied 2 months later. In the following 2 weeks I noticed more bumps, tingling, and shedding (seemed to be 100-150 hairs per day vs. 50-100 normally), so I came back in for a biopsy.

This biopsy was taken very close to my initial biopsy site, but showed no evidence of significant inflammation or fibrosis, a normal number of hair follicles (some miniaturized), and retained sebaceous glands. I saw the derm today, who said my first biopsy could be due to me scratching the folliculitis bumps, or some other reason. But doesn’t think I have a scarring alopecia. Now he has prescribed seracycline (to replace doxycycline), increased the minoxidil to 5 mg/day, and added in roflumilast (Zoryve) foam. I’ve attached some pictures as well. From this information, do you think this could be LPP or CCCA (or folliculitis decalvans?) Or just AGA? Also, any explanation for what could’ve caused the first biopsy to show scarring whereas the second did not?

I get pustules mostly in my crown area, but occasionally in the sides and front as well. They are tender to the touch. There is mild itching. I get random patches of redness on my vertex scalp. No eyebrow or eyelash loss.

BIOPSY 1 (5 months ago)

There is concentric perifollicular fibrosis surrounding the follicular infundibula with associated lymphocytes and histiocytes. There are also fibrotic tracts - some of which contain arrector pili muscles. There are free hair shafts in the reticular dermis. The features are consistent with the surface of scarring folliculitis. The histological differential diagnosis includes a primary scaring alopecia such as lichen planopilaris or central centrifugal cicatricial alopecia.

BIOPSY 2 (2 months ago)

There is a relatively normal number of hair follicles some of which are decreased in size. There is a granulomatous perifolliculitis and non-scarring, non-inflammatory alopecia consistent with androgenetic alopecia. Sebaceous glands are preserved. There is no significant inflammation. PAS stains were negative.

PAST TREATMENTS

I had no treatment of any kind before my hair issues started. Once I noticed hair loss, I tried topical 5% minoxidil foam for 7 months (December 2023-July 2024-no results), 1.5mm microneedling for 6 months (1x per week, Jan 2024-July 2024).

CURRENT TREATMENTS

• Oral minoxidil (started 2.5 mg recently switched to 5 mg).

• Started Aug 2024 Doxycycline 200 mg/day then now changed to sarecycline

• Started August 2024 TSal shampoo and 1% ketoconazole shampoo a few times per week (now changed to Zoryve foam).

PAST MEDICAL HISTORY

Asthma

Anxiety

QUESTION FOR CASE 113

a) What is my diagnosis?

b) how should this be treated?