Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2024;14(4):e2024240 1 Beard Lichen Planopilaris: Report of Two Cases Sara Oulad Ali1, Jihane Belcadi1, Fatima-Zahra Sassine1, Najoua Ammar1, Kawtar Znati2, Mariame Meziane1 1 Department of Dermatology, Mohammed V University in Rabat, Ibn Sina University Hospital, Morocco 2 Department of Histopathology, Mohammed V University in Rabat, Ibn Sina University Hospital, Morocco Key words: Lichen Planopilaris, Beard Alopecia, Dermoscopy Citation: Oulad Ali S, Belcadi J, Sassine FZ, Ammar N, Znati K, Meziane M. Beard Lichen Planopilaris : Report of Two Cases. Dermatol Pract Concept. 2024;14(4):e2024240. DOI: https://doi.org/10.5826/dpc.1404a240 Accepted: July 14, 2024; Published: October 2024 Copyright: ©2024 Oulad Ali 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: Sara Oulad Ali, Department of Dermatology, Mohammed V University in Rabat, Ibn Sina University Hospital, Rabat, Morocco.Email: sarao1993@hotmail.com Introduction Lichen planopilaris (LPP) is a primary lymphocytic scarring alopecia that usually presents with patchy or diffuse per- manent alopecia on the scalp, and rarely on the beard [1]. We herein present two cases of LPP exclusively affecting the beard. Case Presentation The first patient was 51 years old and had a family history of alopecia areata. He presented to our department with a 2-year history of three pruritic alopecic patches on the beard (Figure 1A). Dermoscopic examination revealed significant peripilar hyperkeratosis and erythema with the presence of perifollic- ular tubular scaling (Figure 1B). The second patient was 36 years old and had a history of psychiatric disorders. He presented to our department with a 3-year history of a non-pruritic alopecic patch on the beard. Dermoscopy showed milder peripilar hyperkeratosis and erythema. Both patients did not present any alopecic patches on the scalp nor any other cutaneous, mucosal, or nail involvement. Given these clinical presentations, we considered LPP, trichotillomania, alopecia areata, and tinea barbae for diagnosis. Skin biopsies in both patients were done and revealed in- flammatory infiltrate and significant fibrosis, consistent with cicatricial LPP (Figure 1C). Both patients were treated with topical corticosteroids in combination with 5% topical minoxidil. Discussion The social and individual importance of male facial hair can be compromised by alopecia. The causes are multiple [2] and are represented in Table 1. Lichen planus can affect the beard in various contexts. A series of 20 male patients with frontal fibrosing alopecia (FFA), which is considered a type of LPP, was reported in 2021. All patients had beard involvement, with dermoscopic findings similar to what we observed, including peripilar er- ythema and scaling, with the absence of follicular openings 2 Research Letter | Dermatol Pract Concept. 2024;14(4):e2024240 Figure 1. First patient: (A) One of the alopecic patches on the beard. (B) Peripilar hyperkeratosis and erythema with the presence of perifollicular tubular scaling. (C) Inflammatory infiltrate and significant fibrosis, consistent with cicatricial lichen planopilaris. Hematoxylin-eosin stain; original magnification: ×20. Table 1. Beard alopecia etiologies [2]. Causes Dermoscopy Autoimmune causes Alopecia areata Black dots, yellow dots, tulip hairs, bent hairs, peripilar sign, i-hair, perifollicular hemorrhage Inflammatory causes Lichen planopilaris Frontal fibrosing alopecia Perifollicular scaling, “collar-like” structures, whitish “empty” areas lacking hair shafts, and follicular openings Folliculitis decalvans Perifollicular erythema and scale, follicular hyperkeratosis, pustules, tufted hairs, and white dots. Traumatic causes Trichotillomania Perifollicular hemorrhages Traction alopecia Lack of follicular openings, black dots, and broken hairs at various lengths Infectious causes Herpetic folliculitis No characteristic findings Tinea barbae Corkscrew hairs, comma hairs, zigzag hairs, bent hairs, broken hairs, black dots, and morse code-like hairs, perifollicular scaling Secondary syphilis Very few, small terminal hairs Iatrogenic causes Chemotherapy Black dots, broken hairs, exclamation mark hairs, flame hairs, follicle miniaturization, and pohl pinkus, yellow dots, vellus-like hairs, pigtail hairs Antiretrovirals Anti-Parkinsonian medications Deoxycholic acid injections Botulinum toxin injection Ocrelizumab No trichoscopic findings noted Tumoral causes Mycosis fungoides Sézary syndrome Decreased follicular openings, milky-white globules, yellow dots, black dots/broken hair, structureless patches, perifollicular white or hyperpigmented halos, short fine vessels, perifollicular scaling Research Letter | Dermatol Pract Concept. 2024;14(4):e2024240 3 as well as white, black, and yellow dots and fine linear vessels [3]. In 2022, a multicenter study conducted in the United States involving 270 male patients reported beard alopecia in eight patients with FFA and five patients with LPP, with- out specifying whether these five patients had other sites in- volvement [1]. And lastly, in 2023, a case of lichen planus pigmento- sus on the beard was reported in a 29-year-old patient after using a cosmetic oil for hair growth, although without alo- pecia [4]. Both of our patients denied using a cosmetic product be- fore the development of alopecic patches, and they did not present any sign of FFA. For treatment, corticosteroids are the primary therapeu- tic option [5]. Depending on the case, they are used as topical treatment (clobetasol propionate 0.05%), intralesional cor- ticosteroids (monthly injections), or systemic corticosteroids in more severe cases to stop the flare-up and prevent recur- rences. Corticosteroids can be combined with minoxidil or platelet‐rich plasma. If the therapeutic response is not satisfactory, other med- ical options, including tacrolimus, hydroxychloroquine, cyc- losporine, or methotrexate, can be considered. Unfortunately, scarring alopecia caused by LPP is irre- versible, and modern techniques of hair transplantation can help in stable cases for at least one year [5]. Conclusion The etiologies of beard alopecia are multiple, and the nega- tive psychosocial impact of these conditions on men should prompt early and accurate diagnosis and treatment. References 1. Pathoulas JT, Flanagan KE, Walker CJ, et al. A multicenter de- scriptive analysis of 270 men with frontal fibrosing alopecia and lichen planopilaris in the United States. J Am Acad Dermatol. 2023 Apr;88(4):937-939. DOI: 10.1016/j.jaad.2022.10.060. Epub 2022 Nov 15. PMID: 36396001. 2. Kaiser M, Abdin R, Yaghi M, Gaumond SI, Jimenez JJ, Issa NT. Beard Alopecia: An Updated and Comprehensive Review of Etiologies, Presentation and Treatment. J Clin Med. 2023 Jul 20;12(14):4793. DOI: 10.3390/jcm12144793. PMID: 37510908; PMCID: PMC10381635. 3. Bernárdez C, Saceda-Corralo D, Gil-Redondo R et al. Beard loss in men with frontal fibrosing alopecia. J Am Acad Derma- tol. 2022 Jan;86(1):181-183. DOI: 10.1016/j.jaad.2021.01.032. Epub 2021 Jan 20. PMID: 33484769. 4. Divyalakshmi C, Sukumaran P, Selvadurairaj S, Lourdhurajan R. Lichen planus pigmentosus: A rare case of contact sensitization to beard cosmetic oil. Contact Dermatitis. 2023 Aug;89(2):130-132. DOI: 10.1111/cod.14336. Epub 2023 May 23. PMID: 37221676. 5. Svigos K, Yin L, Fried L, Lo Sicco K, Shapiro J. A Practical Approach to the Diagnosis and Management of Classic Lichen Planopilaris. Am J Clin Dermatol. 2021 Sep;22(5):681-692. DOI: 10.1007 /s40257-021-00630-7. Epub 2021 Aug 4. PMID: 34347282.