Answer: Well, that sounds like follicular lichen planus, also known as lichen planopilaris, attacking your hair follicles. But you need to head straight to a dermatologist for an accurate diagnosis, which could be many other things. We also call this condition you describe, scarring alopecia because unlike the smooth bald patches of alopecia areata or pattern baldness, these bald patches have raised and discolored scar tissue in them initially caused by the immune system attack on your hair follicles. We do know that lichen planus is not contagious. It can also attack the mucous membranes in the genitals or mouth (called oral or mucosal lichen planus), finger or toe nails, or anywhere on the skin especially hairy areas like eyebrows (called cutaneous lichen planus). Many times attacks are on both the head and body at the same time or several locations at once. The exact reason for this attack is unknown, but reddish or brownish raised outbreaks resembling the "lichen" shape (flat round-ish moss common on tree trunks) can be triggered by:
- Allergies to any substance or food
- A viral infection such as hepatitis
- Specific vaccines and many medications
It is also clear that lichen planus attacks 4 times more females than males and most commonly appears in middle age, between the ages of 30 and 70. How lichen planus appears on the scalp Initially you may notice some small or spiny red bumps around involved follicles which may or may not be itchy. This eventually forms scar tissue which damages hair follicles and causes hair to fall out and not grow back. You may also notice unaffected tufts of normal- hair within the scarred areas, which still may appear raised and/or discolored. Gradually hair is lost and replaced with smooth skin, with loss of follicular markings because at this point, hair loss is permanent (we call this Pseudopelade of Brocq if a cause such as lichen planus or alopecia areata is not the cause and the cause is unknown.) How we treat lichen planus If outbreaks are linked to an allergy or drug, identifying and avoiding that substance can help resolve the problem and avoid additional outbreaks. But many times oral lichen planus is a chronic auto-immune condition in which flare-ups continue to come and go over a long period of time, with lesions lasting for days, weeks or even months. Some cases may resolve in 2 years, although approximately 1 in 5 people will have a second outbreak. Since there is no known cure for lichen planus, treatment focuses on alleviating discomfort and promoting the healing of lesions before scar tissue has a chance to form and destroy hair follicles. We like to prescribe steroid medication initially to see if we can halt the reaction, which does help immediately resolve inflamed, scarring tissue. But steroid treatment is a short-term solution only, not to be continued for the long-term because oral and injected steroids increase the risk for osteoporosis, diabetes, high blood pressure and high cholesterol. The bad news: Once steroid treatment is halted, lesions may return. So, because there is no known treatment protocol that works for everybody, we alternate and try all the treatments below to see if we can mitigate the scarring and preserve hair your follicles:
- Antihistamines: Internal medication to help alleviate itching so you don't scratch and cause scars
- Topical corticosteroid: A topical medication in cream or ointment form used to reduce swelling, itching and redness.
- Corticosteroid: Internal medication (such as prednisone) or shots to alleviate a serious attack of swelling, pain or many lesions at one time.
- PUVA light therapy: A type of light treatment used for eczema and psoriasis conditions that may help clear the skin of scarring lesions.
- Retinoic acid: Topical or internal medication to help clear lesions.
- Tacrolimus ointment or pimecrolimus cream: A topical medication that is not a steroid (so it can be used for longer duration) used for severe eczema cases that may help clear lesions.
The most important thing is not to give up and keep alternating and trying the different medications to stop the scarring and the hair loss and save your hair. -Jodi
Question: Can I be causing my own hair loss problem? I have a habit of tugging and twisting on individual hairs every day and even pulling some out and I've noticed some spots where my hair seems to be thinning. What should I do?
This is actually a hair loss disease, but it is psychological in nature rather than physical. The disease is pronounced: trik- oh-till-oh-may-nee-ah. People also call it ‘Trich’ or TTM for short. I can tell if a patient is suffering from this disease rather than something physical such as pattern baldness or auto-immune such as alopecia areata because if I feel stubble in the bald spots, it tells me that hair is growing back normally, although it might have been removed. Bald patches of alopecia areata feel smooth and so do pattern baldness spots because hair is not growing back normally and the growth cycle is disrupted for a physical reason. I suggest a visit to a dermatologist to get an accurate diagnosis. It's a compulsion to pull your hair out…literally. If you feel a strong compulsion to pull out hairs, as you said, you may very well be causing your hair loss. In some patients, the compulsion to pull at hairs is so strong, they feel they can't stop, but others can learn to control it through awareness or will power. Trich does not affect everyone who suffers from it the same way or to the same degree. Some pull hair deliberately and some pull hair out unconsciously and some people pull only scalp hair while others may pull facial hair such as eyelashes and eyebrows or body hair on legs and arms. Some patients pull any and all hair. Some Trich patients just pick up hairs and roll them between fingers. Hair loss can become permanent The longer the hair pulling and twisting habit goes on, the more severe the hair loss may be. In extreme cases, hair loss can become permanent because hair follicles can become damaged to the point of death. In milder cases, hair keeps re-growing, although eyelashes and eyebrows take a notoriously long time to grow back. A dermatologist can confirm the health of hair follicles and a prognosis for hair re-growth.
- What's the prognosis and treatment for Trich? Researchers are unsure how the compulsion to pull out hair starts.
- Past statistics on the disease show that Trich can strike happy, well-adjusted people as often as emotionally disturbed or depressed people. these same statistics show that Trich behavior usually starts in early adolescence and that 90 percent of sufferers are women.
- I think that the statistics may be a little more skewed towards women because Trich is a less satisfying compulsion and less noticeable in men with short hair and male pattern baldness and maybe less men seek medical attention for such a habit. Current research on Trich shows that similar brain chemical imbalances that cause depression or bulimia can cause Trich behavior and treatment with anti-depressant medications may help curb the compulsion to pull at hairs and allow hair to grow back. A Psychologist can help you determine your best course of action once a diagnosis is made.