Scarring alopecia suggestive of Lichen Planopilaris - Could this diagnosis be inaccurate? (Photos)

Thank you for sharing your concerns and the details of your biopsy. I understand how confusing it can be when your clinical appearance doesn’t fully match the biopsy report. Let me address your questions as clearly as possible:

False positives on scalp biopsies: While scalp biopsies are generally reliable, they are not perfect. Sampling errors can occur, and interpretation can sometimes be challenging, especially in early or subtle cases. So yes, it is possible, though uncommon, for a biopsy to suggest scarring alopecia even if the clinical picture seems more like androgenetic alopecia.

Could it describe androgenetic alopecia or alopecia areata instead?

Androgenetic alopecia (pattern hair loss) usually shows miniaturization of hair follicles without scarring.

Alopecia areata typically shows a different pattern of inflammation and follicle damage that is non-scarring.

A biopsy showing “scarring alopecia suggestive of Lichen Planopilaris” usually points toward permanent follicle loss, not typical pattern hair loss. However, if the biopsy was taken from an early or atypical area, overlap can make interpretation tricky.

Effect of washing or scrubbing scalp: Scrubbing your scalp before the biopsy generally does not cause the microscopic changes seen in scarring alopecia. Trauma from washing or scratching is unlikely to mimic the findings of Lichen Planopilaris on a biopsy.

Need for a repeat biopsy: Sometimes a second biopsy is helpful if the first one is inconclusive or does not match the clinical picture. However, in many cases, a single biopsy is sufficient to make the diagnosis. Decisions about repeating it usually depend on ongoing progression, response to treatment, and correlation with your clinical appearance.

Does the biopsy mean scarring has already occurred?

If the report says “scarring alopecia suggestive of Lichen Planopilaris,” it indicates that some degree of permanent follicle damage has already started.

However, in early Lichen Planopilaris, there may still be areas where hair can regrow if inflammation is treated promptly. Early intervention is key to preventing further loss.

Summary: Your biopsy is important evidence, but it is best interpreted alongside your hair pattern, clinical exam, and progression over time. Early or subtle Lichen Planopilaris can sometimes overlap with other types of hair loss, and treatment decisions often depend on both biopsy results and ongoing monitoring.

So, you need to understand that in order to diagnose hair loss we need three things: 1) a full story 2) a chance to examine the scalp and 3) a review of any tests. I don’t have your story and I can’t examine your entire scalp. Therefore, by strict definition, I cannot say anything about your diagnosis. But i can make a few generalizations. Your biopsies have very little in the way of convincing evidence for LPP. Could it still be? Sure. It is likely? Probably not. Again, i need the full lifelong story of hair loss and a chance to see your scalp up close. A repeat biopsy or re-interpretation of the current biopsy by an expert in dermatopathology will be useful. No scratching your head is not the cause. See an expert for full review