An appreciation of the differences in the severity and the symptoms of lichen planopilaris (LPP), an inflammatory scarring alopecia, should be put to use to individualize therapy, according to an expert who has published frequently on this condition.

Based on numerous studies and empirical experience, the algorithm provides a rationale that starts with assessing the rate of progression and extent of involvement to final steps that might include multimodal therapies, according to Jerry Shapiro, MD, professor, Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine, New York City.

As an expert who has devoted and limited his practice to hair disorders, Shapiro treats LPP on a regular basis. Because of its heterogeneity and unpredictable course, the disease can be challenging, but he has developed treatment pathways to optimize the benefit-to-risk ratio, and he keeps patients informed of the steps.

Patients Are Provided With Treatment Algorithm

“I show my algorithm to every patient. They like to see the plan we are going to use,” said Shapiro, who provided a detailed review of his approach in a presentation at Maui Derm Hawaii 2026. 

Once diagnosed, a process that involves demonstrating characteristic inflammation on biopsy, observing hyperkeratosis and perifollicular scaling on magnification, and a positive hair-pull test, the first decision point is the speed of progression. Shapiro said a gradual onset of hair loss with pain and burning is typical but cicatricial hair loss is generally permanent, so control of inflammation is urgent when progression is rapid.

As a result, he called rapid progression of LPP a “trichologic emergency,” and he addresses it with oral prednisone in the effort to stop or slow a process that needs an aggressive approach to preserve existing hair follicles.

After speed of progression, the next decision point is informed by extent of disease. For those with < 10% scalp involvement, he starts with monthly injections of 10 mg/cc intralesional triamcinolone acetonide (TAC) combined with twice daily applications of an anti-inflammatory-based topical compound that consists of 0.3% tacrolimus, clobetasol, and 5% minoxidil (TCM).

If this stabilizes the disease, treatment is maintained as needed. If it does not or if patients have > 10% scalp involvement at the time of diagnosis, he uses the same regimen but adds doxycycline and hydroxychloroquine.

“We used to prescribe doxycycline in a dose of 100 mg twice daily, but we now use less,” Shapiro reported. This is based on a recent study he coauthored, which compared 100 mg to low-dose doxycycline, including 20 mg twice daily, in patients diagnosed with a lymphocytic scarring alopecia (50% had LPP). He described the study as a comparison between doxycycline as an antimicrobial vs an anti-inflammatory strength. The lower dose was just as effective.

“So we now know that you do not have to give the 100 mg dose, which is often associated with an upset stomach and other problems,” he said, noting that trademarked and generic 20 mg formulations are available.

Shapiro recommends hydroxychloroquine in a 200-mg dose twice daily, but if stabilization is not reached on these four initial compounds (intralesional TAC, TCM, doxycycline, and hydroxychloroquine), he adds 15 mg pioglitazone once daily and 3 mg of naltrexone once daily.

Peroxisome Proliferator-Activated Receptor (PPAR)-Gamma Agonist Revives Sebaceous Gland

“Pioglitazone is a PPAR-gamma agonist that normalizes lipid synthesis in the sebaceous gland for a more functional hair shaft,” Shapiro reported. Naltrexone is an immune system modulator that is now used in several forms of alopecia, according to Shapiro, who was the senior author of a case report in 2017 showing benefit of low-dose naltrexone for LPP in four patients.

If these steps still do not lead to stabilization, Shapiro reaches deeper into a list of therapies with anti-inflammatory effects, including JAK inhibitors, mycophenolate mofetil, methotrexate, and cyclosporine. He considers use of low-dose isotretinoin, a drug that paradoxically has been associated with hair loss in patients with acne, in selected cases.

To stimulate hair regrowth, Shapiro said he often uses the 308-nm excimer laser, but he cautioned that reimbursement can be problematic. He typically seeks preapproval on the basis of medical need, but it has not been granted uniformly.

More than 5 years ago, he coauthored a study of platelet-rich plasma (PRP) in LPP, which concluded that the “relative therapeutic contribution of PRP remains unclear,” although the study found that it was not harmful in patients with this disease.

Shapiro cautioned that hair transplants for patients recovering from LPP should not be attempted for at least 2 years after disease activity has been controlled, because of the risk for koebnerization.

Considered an autoimmune disorder even if the pathophysiology is not completely understood, LPP is one of seven lymphocytic cicatricial forms of alopecia that Shapiro treats. These lymphocytic disorders are distinct from neutrophilic scarring subtypes, such as folliculitis decalvans or dissecting cellulitis, and mixed scarring alopecia, such as folliculitis keloidalis, but they all result in destruction of the hair follicle if not treated early, he said. He estimated that about a third of his practice is devoted to cicatricial alopecia, and each requires extensive counseling to understand and meet patient goals.

“I spend about an hour with every patient I see,” Shapiro said. He feels the effort to fully understand the patient’s needs and answer their questions is repaid in developing a collaborative relationship and patient satisfaction.

Shapiro disclosed having financial relationships with AbbVie, DS Laboratories, Eirion, Lilly, Pfizer, Thirty Madison, and Veradermics.