Biopsy for diffuse hair loss revealed LPP, but can this possibly not be LPP?

Diagnosing conditions like Lichen Planopilaris (LPP) can be challenging, particularly when biopsy results are not entirely consistent. LPP is a type of scarring alopecia characterized by lymphocytic inflammation around hair follicles, which can lead to hair loss. The biopsy description you provided does show features that are suggestive of LPP, such as the mild perifollicular inflammatory infiltrate and perifollicular mucinous fibroplasia.

However, the presence of androgenetic alopecia (AGA) without LPP in another biopsy adds complexity to the diagnosis. It is possible for a patient to have both conditions simultaneously, as AGA affects the hair cycle and density, while LPP causes inflammatory changes.

Given these mixed findings, it would be advisable to discuss the results with your dermatologist. They might recommend a few steps to clarify the diagnosis:

Clinical Correlation: Assess the clinical presentation and correlate it with the biopsy findings. The pattern and progression of hair loss, any symptoms like itching or burning, and the presence of other signs on the scalp can provide additional context.

Repeat Biopsy: In some cases, a repeat biopsy from a different area of the scalp might be necessary to confirm the diagnosis, especially if the clinical picture does not align with the biopsy results.

Additional Testing: Consider other tests or imaging studies that might help in distinguishing between these conditions.

Treatment Response: Sometimes, the response to treatment can help clarify the diagnosis. Treatments for LPP and AGA differ significantly, and observing how your hair loss responds can provide more information.

Ultimately, a thorough discussion with your dermatologist is crucial to determine the best course of action and to ensure a comprehensive approach to your hair loss concerns.

As a dermatopathologist and dermatologist specializing in hair loss treatment, I can say that the pathology of hair loss is highly complex. Some degree of inflammation occurs in androgenetic alopecia (pattern hair loss), which can sometimes be misdiagnosed as lichen planopilaris (LPP). It’s essential for the physician to take a comprehensive approach, integrating clinical examination, trichoscopy, and dermatopathology findings to make an accurate diagnosis. If you would like a second opinion, I would be happy to consult with you at my clinic performing a clinical examination, trichoscopy and I may examine your biopsy specimen. Best of luck, Dr. K

Hi there,

I understand how confusing and overwhelming mixed biopsy results can be. Based on the findings, it’s possible that you have early Lichen Planopilaris (LPP), as one biopsy suggests, but the other biopsy pointing to Androgenetic Alopecia (AGA) without LPP adds some complexity. The good news is that LPP isn’t a guaranteed diagnosis here—it’s possible this is only AGA with some inflammation, or there could be a mix of both conditions.

Diagnosing hair loss isn’t just about biopsy results—it also involves understanding your full story, examining your scalp (often with trichoscopy), and considering everything together. Your doctor might suggest further evaluation or a more detailed biopsy report to help clarify things.

In the meantime, there are treatments for both LPP and AGA, so don’t lose hope. Stay in touch with your dermatologist, and keep an eye on any changes. You’re on the right path!

PS no photographs or indication whether male or female in this case. Approach differs.

Sure, there is a small chance it’s not. There are subtle hints at a diagnosis of LPP but yes it’s incomplete and there is a chance you don’t have (there is also a chance you have). You need to take really special note as to how we reach a diagnosis of somebody’s hair loss. it’s NOT by staring at a biopsy report over and over. That’s where mistakes happen. We reach a diagnosis of hair loss by reviewing THREE things all AT THE SAME TIME. This includes 1) the entirety of the patient’s story of hair loss and their general health and 2) what exactly things look like on trichoscopy and 3). The findings of the biopsy. We need all three. You have given me one of the three things that are needed so of course there is no way of saying what is really and truly going on in your case. And even with this biopsy I would not even begin to say I have all the biopsy information I need. You’re going to want to speak to your doctors and ask for a more complete pathology report (if your doctor feels it’s needed). You see, in a situation like this, I also need to know 1) are sebaceous glands lost or not??? 2) is their any evidence of follicular keratinocyte necrosis or lichenoid changes?? 3) are elastic fibers altered on VVG special stains??? Your biopsy report does not have all the information that is really needed in a challenging situation like this!!. one should never be too fooled into thinking perifollicular inflammation and perifollicular fibrosis equates to LPP. No! Those can be features of AGA in some cases. All in all, one needs to remember that we don’t diagnose hair loss solely by staring a biopsy reports. The clinical and examination findings TOGETHER with a good and complete biopsy report is what is needed. Be sure to speak to your doctor and interpreting dermatopathologist about these issues.