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Red scalp is a common complaint that may constitute a diagnostic and therapeutic challenge in daily clinical practice. Among the numerous diseases to cause diffuse scalp erythema are psoriasis, seborrhoeic dermatitis, contact dermatitis, diffuse lichen planopilaris, dermatomyositis and scalp rosacea. Accurate diagnosis is crucial for optimal treatment outcomes. Histology most frequently discriminates the underlying condition, but it requires scalp biopsy. In many cases, the combination of clinical examination and trichoscopy is sufficient for establishing the correct diagnosis. The main trichoscopic features of psoriasis are silver-white scaling, regularly distributed dotted (glomerular) vessels or twisted red loops, and punctate haemorrhages. Yellowish-white scaling and thin arborizing vessels are typical features of seborrhoeic dermatitis. Contact dermatitis is characterized by the presence of yellow exudate and polymorphic vessels, while perifollicular scaling and erythema with the lack of follicular openings are typical findings in lichen planopilaris. In scalp dermatomyositis, tortuous and arborizing vessels with interfollicular and perifollicular pigmentation may be detected. The most characteristic features of scalp rosacea are perifollicular scaling and polygonal/arborizing vessels. This review also summarizes histological features and therapeutic options for these conditions., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Association of Dermatologists. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Lichen planus (LP) presents with a range of clinical subtypes. It can affect the outer skin, involve the nails and present with alopecia and mucosal symptoms to varying degrees. LP of the outer skin mostly shows a self-limiting course; however, this is not the case for lichen planopilaris and the mucosa-affecting subtypes. The pathogenesis of LP is still incompletely understood. As a result, an effective, targeted therapy is currently lacking and different immunomodulatory approaches are being used in clinical practice. The management of patients with severe oral LP mucosae can be particularly challenging. Although the true risk remains controversial, oral LP is considered a risk factor for the development of squamous cell carcinoma and there is a need for regular screening. The quality of life in patients with LP is significantly impaired because of frequent clinical visits, pain, soreness, inability to eat certain foods, side effects to medication, frustrating therapy attempts and worry regarding cancer risk. We highlight here the advantages of an interdisciplinary dermatology and oral surgery clinic, which can address the domains of tooth status, nutrition, pain and malignant transformation and optimized patient management., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Association of Dermatologists. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Lichen planus-like keratosis is a common, benign pigmented skin lesion. It should be carefully diagnosed using modern diagnostic tools, such as dermoscopy and confocal microscopy, to avoid misdiagnosis as melanoma or other malignant pigmented lesions., (© 2022 British Association of Dermatologists.)

Primary cicatricial alopecia (PCA), also known as scarring alopecia, comprises a diverse group of hair disorders that cause permanent destruction of the pilosebaceous unit, resulting in disappearance of the follicular ostia. Lichen planopilaris (LPP) is a subtype of primary lymphocytic cicatricial alopecia. There is an urgent need to identify novel molecules that successfully target specific pathogenic pathways in LPP to inhibit and reverse disease progression. Recent studies into LPP pathogenesis have discovered that follicular stem cells undergo epithelial-mesenchymal transition (EMT). We sought to identify drugs that target molecules involved in EMT to repurpose these drugs for treatment of LPP. We identified 8 molecules and 15 drugs that target these EMT molecules. Only four of these drugs (pioglitazone, tofacitinib, barcitinib and apremilast) have been reported in individual cases or case series of patients with LPP and controlled studies are missing. We describe each drug and mechanism of action target EMT in detail. Although previous studies have demonstrated the efficacy of EMT inhibitors in anticancer therapy, there are, to our knowledge, no studies using EMT-attenuating drugs for the treatment of LPP. The treatment molecules discussed in this paper provide a new platform for clinical studies and controlled trials in LPP., (© 2022 British Association of Dermatologists.)

Annular lichen planus is a rare clinical variant of the lichen planus presenting with round-oval, red to brown macules and plaques with no central atrophy and slightly raised, nonscaly borders. Histopathological features are indistinguishable from typical lichen planus. Given that the accurate diagnosis relies on both the clinical presentation and typical histological features, it is important to be aware of the clinical spectrum of lichen planus. Click https://wileyhealthlearning.com/#/online-courses/6be3b20c-e9c3-40e9-8f36-bfcda6718a73 for the corresponding questions to this CME article., (© 2022 The Authors. Clinical and Experimental Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

This retrospective study performed to investigate direct immunofluorescence (DIF) findings in oral and cutaneous lichen planus (LP), and to identify any differences between them. There were 147 patients with a definite diagnosis of LP by clinical and histological criteria, with 87 (59.2%) oral and 60 (40.8%) cutaneous specimens. Of these, 125 (85%) had positive DIF findings, with positive yields being significantly lower in oral (79.3%) than in cutaneous (93.3%) LP. Deposition of immunoreactants at the dermoepidermal junction (DEJ) was significantly greater in oral than in cutaneous LP, and fibrin deposition with shaggy pattern at the DEJ was also significantly greater in oral than in cutaneous LP. Deposition of immunoreactants at colloid bodies (CBs) with or without DEJ was significantly greater in cutaneous than in oral LP. IgM deposition at CBs was commonly detected in both groups. We propose that fibrin deposition with shaggy pattern at the DEJ is the best diagnostic indicator of oral LP., (© 2021 British Association of Dermatologists.)

Background: Frontal fibrosing alopecia (FFA) has become one of the most common causes of cicatricial alopecia worldwide. However, there is a lack of clear aetiology and robust clinical trial evidence for the efficacy and safety of agents currently used for treatment., Objectives: To enable data to be collected worldwide on FFA using common criteria and assessment methods., Methods: A multicentre, international group of experts in hair loss was convened by email to create consensus recommendations for clinical trials. Consensus was defined at > 90% agreement on each recommended part of these guidelines., Results: Standardized diagnostic criteria, severity rating, staging, and investigator and patient assessment of scalp hair loss and other clinical features of FFA were created., Conclusions: These guidelines should allow the collection of reliable aggregate data on FFA and advance efforts in both clinical and basic research to close knowledge gaps in this condition., (© 2021 British Association of Dermatologists.)

Background: Facial papules (FPs) are considered to be created by the inflammatory process, which involves facial vellus hairs, in frontal fibrosing alopecia., Aim: To demonstrate the histopathological features of FPs and the composition of the inflammatory infiltrate., Methods: In total, 18 patients with FPs were enrolled in the study after histopathological confirmation of lichen planopilaris. Histopathological evaluation of the specimens was performed by two dermatopathologists. The samples were immunostained with CD4, CD8 and CD123 monoclonal antibodies, and the percentage and proportion of cells stained with these markers were investigated., Results: A follicular lichenoid reaction and perifollicular fibrosis were present in all cases. Vellus hairs were detected in 83.3% of biopsy specimens (15 cases), all of which were involved by the inflammation. The majority of the follicles (72%) revealed follicular plugs. Reduction and destruction of elastic fibres were visible in the perifollicular (adventitial) and the papillary dermis (100% and 78% of specimens, respectively). Prominent sebaceous glands and dilated ducts were detected in 78% and 72% of samples, respectively. CD4-positive T cells formed 67.72% and CD8-positive T cells 32.28% of the infiltrate, and the mean CD4/CD8 ratio was 2.48. In 13 (72.2%) biopsy specimens < 10% of the infiltrate was positive for CD123 marker., Conclusions: Perifollicular inflammation, fibrosis and elastic-fibre destruction were constant histopathological features of FPs; furthermore, prominent sebaceous glands were present in the majority of samples. We also observed a CD4-positive predominance in the infiltrate., (© 2021 British Association of Dermatologists.)

Lichen planus pemphigoides (LPP) is a rare autoimmune subepidermal blistering disease characterized by the coexistence of both lichen planus and either bullous pemphigoid or mucous membrane pemphigoid (MMP) features. Frontal fibrosing alopecia (FFA) is a scarring alopecia, generally considered a form of lichen planopilaris. We report two patients with concomitant FFA and MPP. Patient 1 was a 73-year-old woman with the clinical and histological diagnosis of oral lichen planus. In addition, she presented alopecic plaques in the parietal area with blisters, immunohistologically compatible with Brunsting-Perry pemphigoid, a variant of MMP. During follow-up, the patient also developed FFA. Patient 2 was a 70-year-old woman with a history of ocular inflammation and desquamative gingivitis, who was diagnosed with MMP based on a conjunctival biopsy. She also had clinical features of FFA. ELISA and frontal biopsy confirmed the diagnoses of MMP and FFA. In conclusion, we report two patients with MMP associated with FFA, and discuss whether this association is a new variant of LPP or an incidental finding., (© 2020 British Association of Dermatologists.)

We present a series of 13 patients with clinical and histological features of both folliculitis decalvans (FD) and lichen planopilaris (LPP), either concomitantly, or sequentially as the clinical phenotype changed over time. This biphasic presentation of FD-LPP is not as uncommon as would be expected from the lack of description in the literature. We discuss current theories about the pathogenesis of both LPP and FD, and speculate how abnormal immune responses may either predispose to secondary bacterial infection or be influenced by dysbiosis of the skin/hair follicle microbiome, resulting in inflammation and permanent hair follicle damage., (© 2019 British Association of Dermatologists.)

Background: Lichen planus (LP) is an inflammatory skin disease with unknown aetiology. Activation by pathogen-associated molecular patterns or environmental stimuli may activate some components of inflammasomes that contribute to the inflammatory process in LP lesions., Aim: To characterize the inflammasomes in skin lesions and peripheral blood mononuclear cells (PBMCs) of patients with LP under Toll-like receptor (TLR) activation., Methods: In total, 15 patients with LP and 14 healthy controls (HCs) were enrolled in the study. Inflammasome expression in skin was evaluated by real-time PCR and immunohistochemistry, while ELISA was used to assess the production of interleukin (IL)-1β by PBMCs under stimulation with TLR4 and TLR7/TLR8 agonists and adenosine triphosphate (ATP)., Results: Compared with the levels in HC samples, increased expression of the inflammasome AIM2 was verified in both epidermal and dermal sections of LP skin lesions, whereas NLRP1 and IL-β expression levels were enhanced in the dermis. LP skin lesion samples exhibited higher AIM2 transcript levels, similar NLRP1 levels and lower pro-IL-1β mRNA levels compared with HC samples. We verified that, compared with PBMCs from HC subjects, PBMCs from patients with LP produced similar amounts of IL-1β after induction by TLR4 agonists but lower IL-1β levels after induction by TLR7/TLR8 agonists, regardless of the addition of ATP., Conclusion: Alterations in innate immunity, such as inflammasome component expression in skin lesions and PBMCs, were observed in patients with LP. Further investigations of dysfunctional inflammasome activation and the chronic inflammatory status of LP are required., (© 2018 British Association of Dermatologists.)

Vaccines have a well-demonstrated therapeutic benefit. However, the spectrum of potential dermatologic vaccine side effects ranges from localized skin irritation to acute and delayed response. Currently, there are limited published data correlating dermatoses with alterations in the immune system following vaccination. The mechanism by which group A beta-hemolytic streptococci may precede the manifestation of guttate psoriasis is included as a mechanism foundation as we further describe the immunopathogenesis of immune-mediated linear dermatoses. We present a rare case of linear lichen planus following intramuscular influenza vaccination, not associated with an injection site reaction. Immune-related dermatoses may be underreported, and a vaccine history should be considered in all patients with a skin condition that is otherwise attributed as idiopathic., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.)

Lichen planus pigmentosus (LPP) is a rare disease characterized by persistent and asymptomatic slate-grey pigmentation, which mostly affects patients with skin types IV-VI. The face and neck are the most commonly involved sites, followed by the trunk and extremities. LPP is believed to spare the palms, soles and nails. In this report, we describe palmoplantar involvement in 10 (4.65%, 10/215) patients with LPP, and compare its clinicodemographic features with those of classic LPP. LPP lesions on the palms and soles present as asymptomatic, well-circumscribed, hyperpigmented, brown-black patches without any history of prior lichen planus lesions. They are mostly observed in young patients with rapidly spreading active disease, who often require systemic treatment to control the disease activity. Strikingly, palmoplantar involvement is frequently associated with other atypical LPP variants. It is important to identify palmoplantar involvement in LPP, as it has a different clinical course and associations compared with classic LPP., (© 2018 British Association of Dermatologists.)

Background: The clinical recognition of lentigo maligna (LM) and LM melanoma can be very challenging due to the overlapping features it shares with other pigmented macules of the skin. Noninvasive diagnostic techniques can assist in the differential diagnosis., Objectives: To identify reflectance confocal microscopy (RCM) indicators for LM through the identification of in vivo microscopic substrates of the main dermoscopic features seen in flat pigmented lesions of the face., Methods: Retrospective analysis of 60 pigmented lesions (LM, invasive melanoma, solar lentigo/flat seborrhoeic keratosis, lichen planus-like keratosis, pigmented actinic keratosis) was carried out. The main dermoscopic patterns and RCM features were described. A new method for correlating RCM with dermoscopic patterns was developed., Results: Pseudonetwork (37 of 60 lesions) and annular granular structures (37 of 60 lesions) were the most frequent dermoscopic patterns, followed by pigmented blotches (27 of 60 lesions). Upon RCM examination, pseudonetwork and blotches differed in melanomas and other nonmelanocytic lesions. These differences included the intraepidermal proliferation of atypical cells (predominantly dendritic-shaped with adnexal tropism) and the presence of a meshwork pattern at the junction. Also, annular granular structures exhibited dendritic cells almost exclusively in melanoma, with no difference between melanomas and nonmelanocytic lesions for the junctional and upper dermal pattern (characterized by dermal inflammation). Fingerprinting was mostly present in nonmelanocytic lesions or corresponded to an overlap with solar lentigo in melanomas., Conclusions: RCM is useful for identifying the histological substrate of dermoscopic features in pigmented lesions of the face. It can provide a better definition of the lesion areas, enabling an improved diagnostic approach., (© 2014 British Association of Dermatologists.)

Background: Dermoscopy is useful in evaluating skin tumours, but its applicability extends also to the field of inflammatory skin disorders. Plaque psoriasis (PP), dermatitis, lichen planus (LP) and pityriasis rosea (PR) are common inflammatory skin diseases, but little is currently known about their dermoscopic features., Objectives: To determine and compare the dermoscopic patterns associated with PP, dermatitis, LP and PR and to assess the validity of certain dermoscopic criteria in the diagnosis of PP., Methods: Patients with PP, dermatitis, LP and PR were prospectively enrolled. The single most recently developed lesion was examined dermoscopically and histopathologically. Variables included vascular morphology, vascular arrangement, background colour, scale colour, scale distribution and presence of Wickham striae. Univariate and adjusted odds ratios were calculated. Discriminant functions were used to plot receiver-operator characteristic curves., Results: Eighty-three patients with PP and 86 patients with either dermatitis, LP or PR were included in the study. Dotted vessels in a regular arrangement over a light red background and white scales were highly predictive for the diagnosis of PP, whereas dermatitis more commonly showed yellow scales and dotted vessels in a patchy arrangement. PR was characterized by yellowish background, dotted vessels and peripheral scales; whitish lines (Wickham striae) were seen exclusively in LP., Conclusions: PP, LP, PR and dermatitis show specific dermoscopic patterns that may aid their clinical diagnosis. Certain combinations of dermoscopic features can reliably predict the diagnosis of PP., (© 2012 The Authors. BJD © 2012 British Association of Dermatologists.)

Cosmetic surgical procedures, including hair transplantation and face-lift surgery, are becoming increasingly popular. However, there is very little information regarding the associated development of dermatological conditions following these procedures. Lichen planopilaris (LPP) is an uncommon inflammatory hair disorder of unknown aetiology that results in permanent alopecia and replacement of hair follicles with scar-like fibrous tissue. Frontal fibrosing alopecia (FFA), a variant of LPP, involves the frontal hairline and shares similar histological findings with those of LPP. We report 10 patients who developed LPP/FFA following cosmetic scalp surgery. Seven patients developed LPP following hair transplantation, and three patients developed FFA following face-lift surgery. In all cases there was no previous history of LPP or FFA. There is currently a lack of evidence to link the procedures of hair transplantation and cosmetic face-lift surgery to LPP and FFA, respectively. This is the first case series to describe this connection and to postulate the possible pathological processes underlying the clinical observation. Explanations include Koebner phenomenon induced by surgical trauma, an autoimmune process targeting an (as yet, unknown) hair follicle antigen liberated during surgery or perhaps a postsurgery proinflammatory milieu inducing hair follicle immune privilege collapse and follicular damage in susceptible individuals., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists 2011.)

Background: Lichen planopilaris (LPP) and discoid lupus erythematosus (DLE) are the most common causes of lymphocytic primary cicatricial alopecia. The management of scarring alopecia can be difficult. The combination of clinical, dermoscopy and reflectance confocal microscopy (RCM), a noninvasive, high-resolution imaging technique, examinations have already been demonstrated to be useful for choosing the correct biopsy site in patients with inflammatory skin disease and obtaining microscopic diagnostic criteria., Objectives: We evaluated the usefulness in practice of RCM for the identification of criteria for LPP and DLE involving the scalp and their management during therapeutic follow-up., Methods: Seven white patients with a previously established histological diagnosis of DLE (three) and LPP (four), were included in the study. RCM criteria for primary scarring alopecia were selected: epidermal disarray, spongiosis, exocytosis of inflammatory cells in the epidermis, interface dermatitis, peri- and intra-adnexal infiltration of inflammatory cells, dilated vessels in the dermis, dermal infiltration of inflammatory cells and melanophages and dermal sclerosis. All patients were followed up using RCM during the treatment. During follow-up the RCM evolution of the epidermal, junctional and dermal inflammation were evaluated., Results: A series of RCM features of scalp LPP and DLE were identified that show correlation with the histopathological evaluation. During the treatment follow-up of the cases RCM was shown to be sensitive for the identification of therapeutic response., Conclusion: In our preliminary study the effective usefulness of RCM for the diagnosis of scarring alopecia and follow-up seemed to be evident. Moreover, RCM seems to be also promising for differential diagnosis between the different entities., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists.)

Background: Autoimmune attack of the bulbar region of anagen phase hair follicles by CD8+ T cells and Th1 cytokines has been proposed to result in hair loss in alopecia areata (AA). The initiating stimuli are unknown. As interferon-alpha therapy may trigger AA, we propose that type 1 interferons are involved in the induction of disease., Objectives: To compare lesional scalp from patients with AA with scalp lesions of cutaneous diseases associated with local type 1 interferon-related protein expression., Methods: Lesional scalp of patients with AA, discoid lupus erythematosus, lichen planopilaris and androgenetic alopecia was examined by immunohistochemistry for expression of the type 1 interferon-inducible myxovirus protein A (MxA), the chemokine receptor CXCR3, and the cytotoxic proteins granzyme B (GrB) and T-cell intracytoplasmic antigen 1 (TiA-1)., Results: MxA was expressed in the intradermal and subcutaneous compartments of the hair follicle including sebaceous glands in inflammatory AA similar to lesions of cicatricial alopecia (discoid lupus erythematosus, lichen planopilaris) but not in the epidermal compartment of AA, and not at all in noninflammatory AA or androgenetic alopecia. The location of CXCR3-expressing cells correlated with MxA expression. The inflammatory cells around the hair follicle in AA included a lower number of GrB+ and TiA-1+ cells compared with cicatricial alopecia and demonstrated predominant TiA-1+ expression., Conclusions: We demonstrate the expression of type 1 interferon-related proteins in the inflammatory lesions of AA. The distribution pattern of the interferon signature and cytotoxicity-associated proteins in AA differs from cicatricial alopecia.

Background: Lichen planus (LP) is uncommon in children, and there have been few large studies on LP in this patient group. Most of the literature on childhood LP has appeared as case reports or isolated case series., Methods: We report the results of a study on 100 children with LP, which is, to our knowledge, the largest study to date on this condition., Results: The mean age of patients was 8.76 years and mean age at disease onset was 7.6 years. The onset of the disease was most commonly seen on the legs (54% of patients). The classic papular lesions were the commonest morphology seen (42% of patients). The oral mucosa was involved in 17% and nail involvement in 19% of children., Conclusion: Vaccination against hepatitis B has been suggested to be causally related to the onset of LP in various published studies. However, only 16 of our patients had been vaccinated against hepatitis B. If there is a causal relationship, more cases of LP in children may occur in the future, as vaccination against hepatitis B becomes routine in India.

A 68-year-old Chinese woman presented with generalized reticulated dark-brown hyperpigmentation on the trunk, face and limbs, oral Wickham's striae, sparse scalp hair and dark-red reticulated streaks on the occiput of the head and on the neck, some dark-red to violaceous papules on the face, scalp and flanks, light-yellow, deep-seated papules on the palms and soles, and small porcelain-white papules on the dorsal and lateral fingers. The histological features were consistent with the diagnosis of lichen planus (LP). To our knowledge, LP-induced generalized reticulated hyperpigmentation is very rare and this is the first report of the clinical features on the fingers, palms and soles.

Paraneoplastic pemphigus (PNP) is a debilitating chronic blistering mucocutaneous disease associated with an underlying neoplasm and a poor prognosis. We present a patient who had been diagnosed and treated for recalcitrant erosive mucocutaneous lichen planus for 3 years with little success. Further investigations established the diagnosis of PNP with underlying Castleman's disease. This case highlights the importance of repeated investigations to exclude PNP in patients with recalcitrant mucosal erosions, especially if atypical features are present.