Discussion and conclusion
LPP is a scaring alopecia presents as patchy or diffuse hair loss
perifollicular erythema, perifollicular scaling and follicular
keratosis. It can be subdivided into 3 variants, including classic LPP
FFA and Graham-Little-Piccardi-Lasseur syndrome (1).
FFA was first described in 1994 by Kossard as a progressive loss of
frontotemporal hairlines in postmenopausal women (13). Although
premenopausal women or even men might be affected, We found a high rate
of premenopausal women affected by FFA (36.8%). In our series, we had 2
men (10.5%) that they presented more severe facial papules than women.
Recently, involvement of facial vellus hairs presenting as peculiar
facial papules have been reported in association with FFA. On the other
hand the disease might extend beyond the frontotemporal hair line and
affect peripheral body hair and lead to loss of eyebrows and eyelashes.
Thus, FFA has been recognized as a generalized than localized process.
FFA may be associated with clinical or serologic evidence of
autoimmunity e.g. hypothyroidism. In concordance with previous reports,
we found a high prevalence of hypothyroidism. Among our patients there
were 3 cases (15.7%) of hypothyroidism and 3 cases (15.7%) of vitamin
D deficiency.
Facial vellus hair involvement present as noninflammatory facial papules
has been described in association with FFA (8). The clinical picture
includes follicular micropapules randomly distributed over the facial
skin, readily more visible over temporal and cheek regions. At the scalp
biopsy, an inflammatory lymphocytic infiltrate around the upper portion
of hair follicle can been observed with common findings of perifolliculr
lamellar fibrosis and fibrosis of follicular tract (15), so that it is
considered as a variant of LPP.
In our experience these skin changes are more prominent in male patients
due to terminal nature of facial hair follicles. In the other hand, aged
patients may have subtle clinical expression because of coexisting
wrinkles and solar elastosis. Premenopausal women present with more
evident papules even before scalp or eyebrows alopecia.
In parallel our observation, Maele et al. have described facial LPP in
the absence of FFA in premenopausal women (12). In current study we
found facial LPP in 9 women (47.3% of our case) in the absence of scalp
involvement whom 7 cases (41.17%) were premenopausal. Because of these
findings this question comes to mind that whether these facial papules
are in the clinical spectrum of FFA or a variant of LPP that can occur
as a single presentation without involvement of other body sites. More
studies and longer follow up studies are need to recognize the nature of
these lesions.
In some studies, histological evaluation of these papules revealed
elastic fiber involvement accompanied with preserved large sebaceous
glands (16).
Retinoids including isotretinoin are known to have several actions
include anti-inflammatory effects and induction of apoptosis in
sebaceous glands. (17). There are some reports of successful treatment
of FFA with topical retinoids (18). Also there is a report of successful
treatment of facial papules in FFA with oral isotretinoin (16). In
addition, we have never observed in our practice FFA or LPP patients
using other treatments (for example hydroxychloroquine, cyclosporine,
methotrexate and prednisolone) have improved their facial lesions.
These observations, prompted us to conduct this study to evaluate the
therapeutic effects of oral isotretinoin as a first-line treatment of
facial LPP. The results were promising, showed the facial papules
dramatically disappeared (42.1%good and 26.3% very good response). It
seems valuable to consider the use of oral isotretinoin for treatment of
facial papules with LPP nature. But more studies with greater number
patients are necessary to better evaluate the efficacy of oral
isotretinoin optimum dosage and treatment duration and comparison
between topical and systemic retinoids and long term fallow up of the
patients and determining the incidence of recurrence after stopping the
treatment.. On the other hand, isotretinoin-induced sebaceous gland
atrophy is not permanent, so long-term follow-up is necessary to confirm
our observations