Scarring alopecia in a woman with psoriasis

Steroids have produced the best treatment outcomes

LPP has an unpredictable course.² Currently, there is no cure, and in areas where follicle destruction has occurred, normal hair growth cannot be restored.² Therefore, treatment should focus on preventing progression and improving symptoms. It is imperative to manage patients’ expectations when dealing with cicatricial hair loss to ensure that they understand the likely outcomes.

Topical corticosteroids alone have shown some efficacy in treating LPP, but intralesional corticosteroids and oral glucocorticosteroids have resulted in better outcomes.⁴ Typical doses for intralesional triamcinolone are up to 1 mL of 10 mg/mL to 40 mg/mL per treatment session, with a one-month interval between treatments. Oral steroids can be used to initially control the disease and would require approximately 1 mg/kg/d of prednisone tapered over 3 to 4 weeks.

Adverse effects. Intralesional steroids can cause atrophy at the injection site and oral steroids can have rebound effects after an oral regimen is completed. This is in addition to other known adverse effects, such as insomnia and mood changes.⁴

Hydroxychloroquine has been reported to help arrest progression of, and control symptoms of, LPP with minimal adverse effects; a typical dosage is 200 mg twice a day.⁴ The 5-alpha-reductase inhibitors finasteride and dutasteride, which inhibit the conversion of testosterone to its more active form of dihydrotestosterone, have also shown similar efficacy.⁴

Topical corticosteroids alone have shown some efficacy in treating LPP, but intralesional corticosteroids and oral glucocorticosteroids have resulted in better outcomes.

Finasteride can be used at a dose of 1 mg/d to 5 mg/d, and dutasteride is most effective at 0.5 to 2.5 mg/d.⁸ In a preliminary trial, pioglitazone (a peroxisome proliferatoractivated receptor gamma [PPAR-gamma] agonist) showed promise as a new treatment modality for LPP, perhaps because tissue expression of PPAR-gamma is decreased in LPP.⁹

A reasonable approach to therapy is to follow a stepwise increase from topical or intralesional corticosteroids to oral glucocorticosteroids, then to hydroxychloroquine or finasteride/dutasteride. The addition of a PPAR-gamma agonist can be added at any stage as adjunct therapy. A referral to a dermatologist may be necessary for refractory cases.

We started our patient on topical clobetasol 0.05% foam, which decreased her pruritus. However, we counseled her that we did not expect hair to regrow in the areas where she’d experienced hair loss. We continue to monitor her, and she would be a candidate for systemic therapy if the topical corticosteroid does not continue to control her disease.

CORRESPONDENCE
Simon Ritchie, MD, San Antonio Military Health System, 59MDSP/SGO7D, 2200 Berquist Drive, Suite 1, Lackland AFB, TX 78236; simon.ritchie@us.af.mil