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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Homogeneous globular network with asymmetric globules peripherally (red arrow). Milia-like cysts and comedo-like openings (in square). B, Confocal microscopy image of 5.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm. The yellow square outlines the area with the bright annular structures and the hyperreflective round structures with a smooth outline (green arrow); on the right, at higher power, the ring pattern is visible at the dermoepidermal junction, with an area of crest fusion (arrow). C, The histologic image shows the presence in the same area of a compound melanocytic nevus and a seborrheic keratosis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Ascanio Armada, R. Gamo Villegas, A. Pampin Franco, F. Pinedo Moraleda" "autores" => array:4 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Ascanio Armada" ] 1 => array:2 [ "nombre" => "R." 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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 2 | 4 | 6 |
| 2024 Octubre | 73 | 47 | 120 |
| 2024 Septiembre | 89 | 35 | 124 |
| 2024 Agosto | 127 | 71 | 198 |
| 2024 Julio | 101 | 31 | 132 |
| 2024 Junio | 111 | 34 | 145 |
| 2024 Mayo | 92 | 32 | 124 |
| 2024 Abril | 80 | 25 | 105 |
| 2024 Marzo | 81 | 36 | 117 |
| 2024 Febrero | 71 | 29 | 100 |
| 2024 Enero | 82 | 36 | 118 |
| 2023 Diciembre | 83 | 22 | 105 |
| 2023 Noviembre | 106 | 28 | 134 |
| 2023 Octubre | 99 | 33 | 132 |
| 2023 Septiembre | 83 | 42 | 125 |
| 2023 Agosto | 57 | 21 | 78 |
| 2023 Julio | 83 | 47 | 130 |
| 2023 Junio | 68 | 24 | 92 |
| 2023 Mayo | 64 | 28 | 92 |
| 2023 Abril | 61 | 24 | 85 |
| 2023 Marzo | 69 | 23 | 92 |
| 2023 Febrero | 47 | 41 | 88 |
| 2023 Enero | 51 | 40 | 91 |
| 2022 Diciembre | 62 | 53 | 115 |
| 2022 Noviembre | 48 | 32 | 80 |
| 2022 Octubre | 41 | 34 | 75 |
| 2022 Septiembre | 39 | 41 | 80 |
| 2022 Agosto | 42 | 48 | 90 |
| 2022 Julio | 45 | 44 | 89 |
| 2022 Junio | 37 | 30 | 67 |
| 2022 Mayo | 65 | 34 | 99 |
| 2022 Abril | 74 | 32 | 106 |
| 2022 Marzo | 58 | 32 | 90 |
| 2022 Febrero | 61 | 35 | 96 |
| 2022 Enero | 73 | 32 | 105 |
| 2021 Diciembre | 65 | 36 | 101 |
| 2021 Noviembre | 88 | 45 | 133 |
| 2021 Octubre | 67 | 46 | 113 |
| 2021 Septiembre | 58 | 42 | 100 |
| 2021 Agosto | 50 | 21 | 71 |
| 2021 Julio | 48 | 24 | 72 |
| 2021 Junio | 40 | 18 | 58 |
| 2021 Mayo | 46 | 41 | 87 |
| 2021 Abril | 125 | 108 | 233 |
| 2021 Marzo | 72 | 31 | 103 |
| 2021 Febrero | 55 | 28 | 83 |
| 2021 Enero | 37 | 16 | 53 |
| 2020 Diciembre | 32 | 17 | 49 |
| 2020 Noviembre | 27 | 30 | 57 |
| 2020 Octubre | 44 | 18 | 62 |
| 2020 Septiembre | 33 | 20 | 53 |
| 2020 Agosto | 37 | 18 | 55 |
| 2020 Julio | 31 | 14 | 45 |
| 2020 Junio | 33 | 30 | 63 |
| 2020 Mayo | 33 | 23 | 56 |
| 2020 Abril | 30 | 16 | 46 |
| 2020 Marzo | 28 | 20 | 48 |
| 2020 Febrero | 6 | 1 | 7 |
| 2020 Enero | 2 | 0 | 2 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 1 | 0 | 1 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 4 | 1 | 5 |
| 2019 Abril | 4 | 1 | 5 |
| 2019 Marzo | 1 | 8 | 9 |
| 2019 Febrero | 3 | 0 | 3 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 3 | 0 | 3 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Febrero | 26 | 3 | 29 |
| 2018 Enero | 37 | 3 | 40 |
| 2017 Diciembre | 64 | 8 | 72 |
| 2017 Noviembre | 55 | 5 | 60 |
| 2017 Octubre | 29 | 5 | 34 |
| 2017 Septiembre | 35 | 6 | 41 |
| 2017 Agosto | 29 | 12 | 41 |
| 2017 Julio | 27 | 7 | 34 |
| 2017 Junio | 32 | 10 | 42 |
| 2017 Mayo | 29 | 11 | 40 |
| 2017 Abril | 30 | 5 | 35 |
| 2017 Marzo | 19 | 17 | 36 |
| 2017 Febrero | 14 | 11 | 25 |
| 2017 Enero | 21 | 11 | 32 |
| 2016 Diciembre | 32 | 16 | 48 |
| 2016 Noviembre | 27 | 20 | 47 |
| 2016 Octubre | 28 | 21 | 49 |
| 2016 Julio | 1 | 1 | 2 |
| 2016 Junio | 0 | 1 | 1 |
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