BH19 De novo lichen planopilaris after hairline-lowering surgery

Abstract

A 24-year-old woman with no previous history of hair loss underwent hairline-lowering surgery (HLS) for cosmetic purposes. Two weeks later, the patient experienced acute postoperative shedding from the forehead to the midscalp. The patient later developed patchy hair loss with erythema and hyperkeratosis on the frontal hairline. There was no previous history of scalp or hair disorders or lichen planus. Punch biopsy confirmed lichen planopilaris (LPP). She received betamethasone scalp application, topical tacrolimus, systemic hydroxychloroquine and minoxidil foam. The patient’s disease activity has stabilized. HLS is a cosmetic procedure to shorten a disproportionately long forehead, due to a genetically high hairline or hairline recession. This surgical option has been successfully utilized in patients with frontal fibrosing alopecia. Complications of HLS include scalp hypoesthesia or paraesthesia, scarring, infection, haematoma and postoperative temporary or permanent alopecia. Following initial postoperative telogen effluvium, our patient later developed persistent inflammation, prompting a biopsy, which led to diagnosis of LPP. LPP is a primary lymphocytic cicatricial alopecia that has been reported to occur following hair transplant surgery, neurosurgery and cosmetic facelifts. To the best of our knowledge, this is the first reported case of biopsy-proven LPP diagnosed after HLS in an individual with no previous LPP history. LPP may develop after physical trauma (Koebner phenomenon) in predisposed individuals. Surgical trauma can lead to inflammation and the collapse of hair follicle bulge immune privilege, resulting in an immune-mediated attack. However, this may not fully account for cases where LPP arises several years postprocedure. In these cases, defective lymphatic flow postsurgery, with subsequent oxidative stress, could induce or sustain the Koebner phenomenon and the hair follicle bulge immune privilege collapse. Other explanations include the surgery unmasking previously undetected LPP. Our case highlights how LPP can be a potential complication of HLS. The incidence and risk factors of LPP post-HLS are currently unknown.