Multiple Clinical Manifestations of Lichenoid Spectrum: A Patient with Frontal Fibrosing Alopecia, Lichen Planus Pigmentosus, and Nail Lichen Planus

Abstract

Introduction: Frontal fibrosing alopecia (FFA) is characterized by irreversible, symmetrical band-like hair loss in the frontotemporal region. Lichen planus pigmentosus (LPP) is a variant of lichen planus (LP) that presents with hyperpigmented macules and patches predominantly in sun-exposed areas. Nail LP is a subtype of LP that can be present alone or with other forms of LP.

Case report: We report a rare case of a 59-year-old woman presenting with symmetrical, gray-brown, hyperpigmented lesions on her neck and face, band-like alopecia in the frontotemporal region, severe onycholysis in two fingernails, and prominent longitudinal ridging in all fingernails. Clinical, dermoscopic, and histological findings established a diagnosis of FFA associated with LPP and nail LP was established.

Discussion/conclusion: In recent years, it has been established that FFA can be associated with LPP and it is thought to be a variant of lichen planopilaris. Nail involvement is rarely reported in FFA or LPP. To our knowledge, the presence of the three conditions in the same patient has not been previously reported. Although rare we would like to emphasize the importance of a careful examination of the nails in patients with FFA and/or LPP to prevent irreversible nail changes.

Keywords: Frontal fibrosing alopecia; Lichen planus pigmentosus; Nail lichen planus.

Fig. 1

a Decreased hair density in the frontotemporal hairline and hyperpigmented patches on the frontotemporal areas. b Dermoscopy of the frontotemporal region of the scalp shows the cicatricial area, loss of follicular openings, perifollicular erythema, and perifollicular scale (polarized dermoscopy, magnification, ×20).

Fig. 2

a Clinical appearance of LP pigmentosus on the neck. b Dermoscopy of the hyperpigmented lesions on the neck shows brown dots and globules in a black pepper-like pattern, sparing skin wrinkles, and follicular openings (contact polarized dermoscopy with ultrasound gel interface, magnification ×20). c Histopathological examination of a hyperpigmented macule on the neck showed mild perivascular infiltrate, pigment incontinence, and melanophages (hematoxylin and eosin stain, ×100).

Fig. 3

a Onycholysis in the right thumb and left fourth fingernail, fissuring in four nails, and prominent longitudinal ridging, and erythronychia in many of the fingernails. b Dermoscopy of the nails reveals the subtle nail findings of LP, such as erythronychia and fissuring. c Prominent erythronychia involving the proximal part of the nail seen with dermoscopic examination (polarized dermoscopy, magnification ×20).