Dermatology: Practical and Conceptual


Image Letter | Dermatol Pract Concept. 2023;13(3):e2023140 1

Positive Anagen Pull Test Predicting 
Lichen Planopilaris Activity

Raíssa Rodriguez Melo1, Rita Fernanda Cortez de Almeida1,  
Michela Valeria Rita Starace2,3, Daniel Fernandes Melo1

1 Department of Dermatology, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil

2 Dermatology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy

3 Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy

Citation: Rodriguez Melo R, Cortez de Almeida RF, Starace MVR, Melo DF. Positive Anagen Pull Test Predicting Lichen Planopilaris 
Activity. Dermatol Pract Concept. 2023;13(3):e2023140. DOI: https://doi.org/10.5826/dpc.1303a140

Accepted: December 2, 2022; Published: July 2023

Copyright: ©2023 Rodriguez Melo et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, 
distribution, and reproduction in any medium, provided the original authors and source are credited.

Funding: None.

Competing interests: None.

Authorship: All authors have contributed significantly to this publication.

Corresponding author: Raíssa Rodriguez Melo, Department of Dermatology, State University of Rio de Janeiro (UERJ), Boulevard 28 de 
Setembro, 77, Rio de Janeiro, Rio de Janeiro, 20551-030, Brazil. Tel: +55 21 28688478; E-mail:rodriguezraissaa@gmail.com

Case Presentation

A healthy 32-year-old Caucasian male complained of 

patches of alopecia on the right temple and mid-scalp that 

started three months before. Physical examination showed 

two irregular patches of scarring alopecia of approximately 

5 cm associated with trichodynia. The patches trichoscopic 

features were consistent with lichen planopilaris (LPP) in the 

acute phase (Figure 1A).

The pull test was positive and revealed golf club-shaped, 

pigmented hair roots on trichoscopy, typical of anagen 

bulbs, surrounded by a translucid root sheath and bleed-

ing area (Figure 1B). A trichoscopy-guided biopsy followed 

by histopathological examination confirmed the suspi-

cion of LPP.

Treatment with topical clobetasol propionate, oral 

 prednisolone 0,5mg/kg/day, and hydroxychloroquine 5mg/

kg/day was started. After 3 months, the patient had im-

proved and presented a negative pull test.

Teaching Point

LPP is a primary scarring alopecia that usually presents with 

hair loss at the vertex or parietal scalp, and may be asso-

ciated with pain, itchiness, burning, or tenderness. The his-

topathology is characterized by perifollicular lymphocytic 

infiltrate at the follicular isthmus and infundibulum. On 

trichoscopy, perifollicular hyperkeratosis and erythema are 

typical signs of active LPP [1,2]. A positive anagen pull test 

consists of anagen bulbs with attached inner and outer root 

sheaths [1-3]. Extraction of anagen hair with thickened roots 

is uncommon and strongly suggests cicatricial alopecia in the 

acute phase [1,2], as the inflammatory infiltrate may prema-

turely release anagen hairs. It has been previously described 

predicting disease activity in discoid lupus erythematosus 

and Brocq’s pseudopelade, since it is compatible with active 

interface dermatitis on histopathology [2,3]. In the reported 

case, it was associated with LPP activity, supported by clini-

cal, trichoscopic, and histopathological findings.



2 Image Letter | Dermatol Pract Concept. 2023;13(3):e2023140

References

1. Harries MJ, Trueb RM, Tosti A, et al. How not to get scared: 

pointers to the correct diagnosis in patients with suspected pri-

mary cicatricial alopecia. Br J Dermatol. 2009;160(3):482-501. 

DOI:10.1111/j.1365-2133.2008.09008.x PMID: 19183169.

2. Lajevardi V, Mahmoudi H, Moghanlou S, Ansari M,  

Teimourpour A, Daneshpazhooh M. Assessing the correlation 

between trichoscopic features in lichen planopilaris and lichen 

 planopilaris activity index.  Australas J Dermatol. 2019;60(3): 

214-218. DOI:10.1111/ajd.13022 PMID: 30957880.

3. Azulay L, Hanauer L, Leal F, Azulay DR. Alopecias cicatriciais. 

In: Atlas de Dermatologia da semiologia ao diagnóstico. 3rd edi-

tion. Rio de Janeiro: Guanabara Koogan; 2020: p156.

Figure 1. (A) Trichoscopy shows erythema and perifollicular hyperkeratosis in lichen planopilaris. (B) Golf club-shaped pigmented 

anagen bulbs surrounded by the root sheath and a bleeding area.