Letter to the Editor
Follicular Lichen Planus Caused by Wig Use: An Unusual Case of Koebner Phenomenon
Liquen plano folicular causado por una peluca: fenómeno de Koebner inusual
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Monteagudo, A. Vilas-Sueiro, M. Cabanillas, C. Durana" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Monteagudo" "email" => array:1 [ 0 => "benigno.monteagudo.sanchez@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Vilas-Sueiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Cabanillas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Durana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario Universitario de Ferrol, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Complejo Hospitalario Universitario de Ferrol, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Liquen plano folicular causado por una peluca: fenómeno de Koebner inusual" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2113 "Ancho" => 1583 "Tamanyo" => 269307 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The underside of the wig with 5 fasteners.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The scarring alopecias (SA) form a group of disorders that provoke permanent hair loss because of the substitution of hair follicles by fibrosis or hyalinized collagen.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The acquired forms can be caused by physical mechanisms, chemical trauma, skin infections, tumors, and other dermatoses such as chronic cutaneous lupus erythematosus or lichen planopilaris (LPP).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Wigs can be used in the treatment of SA. Wigs are classified according to the type of hair and the method of fixation. Their disadvantages include hair rupture caused by the adhesives and traction by the fasteners.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this article we discuss the case of a 58-year-old woman with LPP of the scalp who developed plaques of SA after using a wig.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In her past history she reported hypertension and dyslipidemia and she had been followed up for years in the dermatology department for telogen effluvium, female-pattern androgenetic alopecia, and LPP (confirmed on biopsy). Nine months before the last follow-up consultation, the patient was diagnosed with infiltrating ductal carcinoma of the left breast, for which she received combined radiotherapy and chemotherapy with doxorubicin, cyclophosphamide, and fluorouracil; this produced anagen effluvium that had become repopulated by the time of consultation. The eyebrows were unaffected.</p><p id="par0025" class="elsevierStylePara elsevierViewall">She came to the clinic wearing a wig. On removing the wig, we observed a pale skin with frontal and parietal alopecia, with persistence of a few isolated hairs and areas of follicular hyperkeratosis. Biopsy revealed areas of cicatricial fibrosis with an absence of hair follicles, and other areas with a dense perifollicular lichenoid infiltrate. The hair in the occipital region was preserved (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Interestingly, there were 5 bilateral, symmetrical round plaques of alopecia in the midline frontal, temporal, and retroauricular regions. The dermoscopy image of the retroauricular area showed a loss of follicular orifices and mild erythema. Histopathology revealed preservation of isolated hair follicles with a lichenoid infiltrate and the substitution of other follicles by vertical tracts of scar tissue (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The cause of these plaques of alopecia was the wig that the patient wore a minimum of 7<span class="elsevierStyleHsp" style=""></span>hours a day when working and, more specifically, the fasteners on the underside of the wig to fix it to the head (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). As she no longer had sufficient hair to use the fasteners, she applied double-sided adhesive tape over them. When the position of the fasteners was marked with a dermographic pen, we found they coincided with the totally alopecic plaques in the midline frontal and right and left temporal and retroauricular regions. We made a diagnosis of acquired scarring alopecia secondary to LPP lesions (classic or its frontal fibrosing alopecia variant) that had developed as a Koebner phenomenon due to the pressure of the fasteners when the wig was being worn and due to traction when removing the adhesive tape.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The isomorphic or Koebner phenomenon consists of the appearance of typical lesions of a specific dermatosis in areas of healthy skin previously stimulated by various forms of trauma, such as friction, pressure, or traction. Only psoriasis, vitiligo, and lichen planus are included in the true Koebner phenomenon (category <span class="elsevierStyleSmallCaps">I</span>).<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> LPP, a follicular form of lichen planus, is subdivided according to its clinical presentation into classic LPP, frontal fibrosing alopecia, and Graham-Little-Lassueur-Piccardi syndrome.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Some authors consider there to be a fourth variant whose pattern of distribution can mimic androgenetic alopecia.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The Koebner phenomenon has been described in both classic LPP and frontal fibrosing alopecia. Although LPP can occur after trauma, burns, radiotherapy, or performing break dancing, the majority of cases arise after hair transplant. According to some authors, many patients who develop LPP after hair transplant in the context of androgenetic alopecia actually previously had LPP incorrectly diagnosed as seborrheic dermatitis or folliculitis. It must be noted that active LPP is a contraindication to performing hair transplant.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The following differential diagnoses should be considered:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0055" class="elsevierStylePara elsevierViewall">Pressure alopecia, a disorder that may or may not involve scarring. Several types exist, some very common, such as postoperative alopecia after long operations and anterolateral leg alopecia caused by friction with socks and trousers, and other rarer forms, such as alopecia after resting the head for many hours watching television or annular alopecia of the newborn due to pressure against the mother's pelvis.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,8,9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Alopecia areata, an entity in which the rapid appearance of new plaques (in 1 to 7 days) has been reported as a result of a Koebner phenomenon caused by traction on a hairy perilesional area to obtain hairs for a trichogram.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, very few articles have described the Koebner phenomenon in LPP. We consider this report interesting as it describes the case of a woman with LPP who developed localized plaques of SA affecting only the areas of pressure of the fasteners used to hold her wig in place. We have found no previous reports of this association in the literature.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Monteagudo B, Vilas-Sueiro A, Cabanillas M, Durana C. Liquen plano folicular causado por una peluca: fenómeno de Koebner inusual. Actas Dermosifiliogr. 2016;107:438–440.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1510 "Ancho" => 1000 "Tamanyo" => 177353 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Frontal and parietal alopecia, with isolated hairs and follicular hyperkeratosis. B, Persistence of hair in the occipital region.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2022 "Ancho" => 900 "Tamanyo" => 355234 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Plaques of alopecia (arrows) in the midfrontal and left temporal and retroauricular areas. B, Dermoscopic image of retroauricular area. Loss of follicular orifices. C, Histology of a biopsy from the retroauricular area. A preserved hair follicle with a lichenoid infiltrate and vertical tract of scar-tissue left by the destruction of a follicle. Hematoxylin and eosin, original magnification ×4).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2113 "Ancho" => 1583 "Tamanyo" => 269307 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The underside of the wig with 5 fasteners.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Histopatología de las alopecias. Parte II: Alopecias cicatriciales" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Bernárdez" 1 => "A.M. Molina-Ruiz" 2 => "L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 15 | 21 |
| 2024 October | 73 | 47 | 120 |
| 2024 September | 89 | 35 | 124 |
| 2024 August | 127 | 71 | 198 |
| 2024 July | 101 | 31 | 132 |
| 2024 June | 111 | 34 | 145 |
| 2024 May | 92 | 32 | 124 |
| 2024 April | 80 | 25 | 105 |
| 2024 March | 81 | 36 | 117 |
| 2024 February | 71 | 29 | 100 |
| 2024 January | 82 | 36 | 118 |
| 2023 December | 83 | 22 | 105 |
| 2023 November | 106 | 28 | 134 |
| 2023 October | 99 | 33 | 132 |
| 2023 September | 83 | 42 | 125 |
| 2023 August | 57 | 21 | 78 |
| 2023 July | 83 | 47 | 130 |
| 2023 June | 68 | 24 | 92 |
| 2023 May | 64 | 28 | 92 |
| 2023 April | 61 | 24 | 85 |
| 2023 March | 69 | 23 | 92 |
| 2023 February | 47 | 41 | 88 |
| 2023 January | 51 | 40 | 91 |
| 2022 December | 62 | 53 | 115 |
| 2022 November | 48 | 32 | 80 |
| 2022 October | 41 | 34 | 75 |
| 2022 September | 39 | 41 | 80 |
| 2022 August | 42 | 48 | 90 |
| 2022 July | 45 | 44 | 89 |
| 2022 June | 37 | 30 | 67 |
| 2022 May | 65 | 34 | 99 |
| 2022 April | 74 | 32 | 106 |
| 2022 March | 58 | 32 | 90 |
| 2022 February | 61 | 35 | 96 |
| 2022 January | 73 | 32 | 105 |
| 2021 December | 65 | 36 | 101 |
| 2021 November | 88 | 45 | 133 |
| 2021 October | 67 | 46 | 113 |
| 2021 September | 58 | 42 | 100 |
| 2021 August | 50 | 21 | 71 |
| 2021 July | 48 | 24 | 72 |
| 2021 June | 40 | 18 | 58 |
| 2021 May | 46 | 41 | 87 |
| 2021 April | 125 | 108 | 233 |
| 2021 March | 72 | 31 | 103 |
| 2021 February | 55 | 28 | 83 |
| 2021 January | 37 | 16 | 53 |
| 2020 December | 32 | 17 | 49 |
| 2020 November | 27 | 30 | 57 |
| 2020 October | 44 | 18 | 62 |
| 2020 September | 33 | 20 | 53 |
| 2020 August | 37 | 18 | 55 |
| 2020 July | 31 | 14 | 45 |
| 2020 June | 33 | 30 | 63 |
| 2020 May | 33 | 23 | 56 |
| 2020 April | 30 | 16 | 46 |
| 2020 March | 28 | 20 | 48 |
| 2020 February | 6 | 1 | 7 |
| 2020 January | 2 | 0 | 2 |
| 2019 December | 4 | 0 | 4 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 1 | 0 | 1 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 4 | 1 | 5 |
| 2019 April | 4 | 1 | 5 |
| 2019 March | 1 | 8 | 9 |
| 2019 February | 3 | 0 | 3 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 3 | 0 | 3 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 3 | 0 | 3 |
| 2018 February | 26 | 3 | 29 |
| 2018 January | 37 | 3 | 40 |
| 2017 December | 64 | 8 | 72 |
| 2017 November | 55 | 5 | 60 |
| 2017 October | 29 | 5 | 34 |
| 2017 September | 35 | 6 | 41 |
| 2017 August | 29 | 12 | 41 |
| 2017 July | 27 | 7 | 34 |
| 2017 June | 32 | 10 | 42 |
| 2017 May | 29 | 11 | 40 |
| 2017 April | 30 | 5 | 35 |
| 2017 March | 19 | 17 | 36 |
| 2017 February | 14 | 11 | 25 |
| 2017 January | 21 | 11 | 32 |
| 2016 December | 32 | 16 | 48 |
| 2016 November | 27 | 20 | 47 |
| 2016 October | 28 | 21 | 49 |
| 2016 July | 1 | 1 | 2 |
| 2016 June | 0 | 1 | 1 |
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