Lichen planopilaris caused by wig attachment: A Case of Koebner phenomenon in Frontal Fibrosing Alopecia

Abstract

Frontal fibrosing alopecia (FFA) represents a distinctive condition with a marginal scarring alopecia along the frontal and temporal hairline. Since its original description, the condition has been recognized to represent a more generalized than localized process, with extension beyond the frontotemporal hairline to include the parieto-occipital hairline and involve peculiar facial papules as evidence of facial vellus hair involvement and loss of peripheral body hair. Finally, the association of FFA with oral lichen planus, nail involvement, and concomitant lichen planopilaris (LPP) points to a close relationship to lichen planus. The Koebner phenomenon or isomorphic reaction has been described in lichen planus, LPP, and ultimately FFA, with face-lift procedures and hair restoration surgery having been implicated as the culprits in the latter. We report the first case of FFA in whom LPP developed at the sites of wig attachments, providing the evidence for Koebner phenomenon. Therefore, wigs are to be included to the list of procedures for hair restoration at risk of eliciting an isomorphic reaction in patients with FFA. Ultimately, the association of Koebner phenomenon with LPP-type lesions in FFA may provide further insight into the underlying pathology and nosology of the condition.

Frontal Fibrosing Alopecia: A Review

“…Explanations for these situations include the Koebner phenomenon induced by surgical trauma, or an autoimmune attack from a follicle antigen liberated during surgery or induced by a post-surgery pro-inflammatory environment [ 91 ]. In that way, the Koebner phenomenon may have also been the cause in a woman with FFA who developed LPP in the areas of wig attachments [ 92 ].…”

Scalp trauma in lichen planopilaris: Case reports of disease progression from fire fighter helmet use

“… 3 , 4 , 5 Reports have also been published on LPP developing after wig use, which is important to consider as patients with LPP may utilize wigs as cranial prostheses for camouflage. 6 Although incompletely understood, it is posited that frictional trauma may contribute to LPP by inducing an inflammatory environment that disrupts the normal immune protection of the hair follicle. 7 Others suggest that trauma downregulates peroxisome proliferator–activated receptor γ signaling which has been linked to LPP.…”