Are the results conclusive with LPP and if no scarring is appreciated yet, can the hair be regrown?

Question

I have diffuse lpp/ hair loss. My question being are the results conclusive with LPP and if no scarring is appreciated yet, can the hair be regrown Biopsy: Sections show perifollicular 'onion-skinning' fibrosis and perifollicular lymphocytes. Sebaceous gland atrophy/loss is noted. Follicular dropout and/or scarring is not yet appreciated. Significant miniaturization or increase in telogen hairs are not appreciated. The epidermis is predominantly unremarkable. A PAS stain is negative

Anna Chacon, MD, FAAD · Answer

Hello,

Thank you for your thoughtful and important question — lichen planopilaris (LPP) can be a complex diagnosis, and your biopsy findings offer helpful insights into where you are in the disease process.

From what you've shared, your pathology reveals:

Perifollicular fibrosis ("onion-skinning")

Perifollicular lymphocytic inflammation

Sebaceous gland atrophy or loss

No evident follicular scarring or dropout

No significant miniaturization or telogen shift

Unremarkable epidermis and negative PAS stain

What Does This Mean?
These findings are highly suggestive of early-stage LPP, a primary scarring alopecia. Even though fibrosis (early scarring) and inflammation are present, true follicular dropout or end-stage scarring hasn't occurred yet, which is encouraging.

Can Hair Be Regrown?
Yes, if the follicles are still intact and not fully scarred, hair regrowth is possible, especially with prompt and targeted treatment. The absence of overt follicular dropout or advanced scarring on biopsy suggests that your condition may still be in a treatable phase, and that hair recovery is still feasible.

However, time is of the essence: LPP is an inflammatory condition that, if left uncontrolled, can lead to irreversible scarring and permanent hair loss. The goal is to calm the inflammation before it reaches that point.

What Can Be Done?
A combination approach is typically most effective:

Topical or intralesional corticosteroids to reduce inflammation

Oral anti-inflammatory agents like doxycycline or hydroxychloroquine

Immunomodulators (e.g., low-dose naltrexone or calcineurin inhibitors)

Hair regrowth support (such as topical minoxidil, oral minoxidil, or PRP if inflammation is well-controlled)

Each case of LPP varies, so your treatment plan should be individualized based on symptoms, extent of disease, and response to initial therapies.

Final Thoughts
Your biopsy suggests early-stage LPP with active inflammation but no irreversible scarring yet, this offers a critical window of opportunity for intervention. With the right treatment, not only can we slow or stop disease progression, but we may also see regrowth in areas that haven't been permanently affected.

Jeff Donovan, MD, PhD · Answer

You’ll want to sit down with your dermatologist and have a really good chat. First, you are assuming that a biopsy is the final answer to how we diagnose hair loss. not so! We diagnose hair loss by listening to the story of the patient and performing a really good examination. then, if there is some confusion or uncertainty a biopsy is done. if the results of the biopsy fit with the history and examination findings then yes, you have the answer. if not, another biopsy needs to be done. I have not seen your scalp nor do I know your story. so it’s impossible to say this is 100 % conclusive for LPP. that’s not how this field works. Now, that said, this biopsy sure does suggest a scarring alopecia. But no, this biopsy report could also be similar in a few other scarring alopecias as well. So one needs the full story and full examination findings in order to finalize the diagnosis. only your practitioners know what is actually seen on examination. remember that this is a biopsy of 20-30 hairs out of 100,000 hairs. No, we never make a final assessment of what could be going on throughout a larger area of the scalp based a 20 hairs seen in a tiny biopsy. your doctors need to consider the biopsy plus the history plus the examination findings. That’s how we diagnose hair loss!!!  Finally, let me touch on the concept of regrowth. Yes some regrowth is theoretically possible where this biopsy was taken. but now that biopsy is removed from the scalp so those hairs are not going to come back. If the other regions of the scalp are 100 % representative of your biopsy then yes there could be regrowth. if this biopsy is not really representative then nobody can say. As far as regrowth, nobody can say how easy that will be and how aggressive you will need to treat this. In other words, I don’t know if you will regrow with a few drops of clobetasol daily or whether you’ll need multiple different immunosuppressants to do the job. but yes some degree of regrowth could be possible in this type of biopsy. whether that is 1 % regrowth or 33 % regrowth or 56% regrowth is a bit of a guess. be sure to speak with your dermatologist about these issues.

Are the results conclusive with LPP and if no scarring is appreciated yet, can the hair be regrown?

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Are the results conclusive with LPP and if no scarring is appreciated yet, can the hair be regrown?

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Everything you need to know about Hair Loss Treatment

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